Go back to Onboarding Forms Consent for Health Assessment Please enable JavaScript in your browser to complete this form.Assessment Date *Client Name *The one receiving the careHealthCare assessment done by: *Consent for Care and Service *The general nature of home care services has been explained to me.I have participated in the development of, and agree to, the care and service plan.The nature of the care and services, the expected benefits, material risks and side effects, alternative courses of actions. I have had the opportunity to ask questions and I understand the answers and agree to proceedI understand and appreciate that I may withdraw my consent, in part or in whole, regarding the care and service plan at any time by communicating with Universal Health Hub.I acknowledge my responsibility to provide a safe work environment for Universal Health Hub caregiver while he or she is providing the care and service.I consent to the Universal Health Hub caregiver using the client’s home phone for visit verification purposes.Consent for Release of Records/InformationI consent to the collection, use and disclosure of the Client’s personal information, including personal health information and records as it pertains to the Client’s care and service for the purpose of providing and facilitating client’s careSubstitute Decision Maker Type: Who are you?SelfGuardian of the personAttorney for personal careRepresentative by consent and capacity boardSpouse/partnerChild or ParentParent who has only a right of accessBrother or sisterThe person signing this form on behalf of the person actually receiving the careName of the Substitute Decision MakerConsent of Understanding *I understand the purpose of this Client Consent and that I can refuse to sign it. I acknowledge that I am signing this client consentwilingly and voluntarily for myself or on behalf of the client and that my consent has not been obtained through misrepresentation or fraud.Client/SDM Signature * Clear Signature Signature of person receiving the care or signature of the Substitute Decision Makerokay to pay $50 non-refundable for in-person health assessment *YESUniversal Health Hub Representative Signature Clear Signature Submit
