Please enable JavaScript in your browser to complete this form. PATIENT INFORMATION TitleMr.Mrs.Ms.Miss.Dr.OtherPatient Name *FirstLastGender *MaleFemaleRoom No (if applicable)Approx age in years *Service Address *address where service will be providedContact Phone Number *Contact Email *For invoice and communicationDiagnosed with Diabetes/Borderline Diabetes? *Yes, Type 1Yes, Type 2NoCurrently on Blood Thinners? YesNoPlease indicate if you have, or have had, any of the following: *High Blood PressureCognitively declinedCirculatory ProblemsN/Aslow to heal after cuts? *YesNoany past foot problems or feet surgery? *YesNoService Requested *Only Foot Care (assessment, nail clipping, corn/callus/ingrown toenail treatment, moisturizing and 10 mins. foot massage)Foot Care and added nail fingers trimming for additional $10I understand that I will be given a 3 hour time window on the date of appointment and I will be given invoice to be paid before the appointment *I agree to pay before the service once the date & time of the appointment is confirmed.Payor Name * -I hereby state that the above information is true and accurate and give my permission and consent for Universal Health Hub to provide foot care service. -I understand that I am financially responsible for all charges whether covered by my health insurance plan or not. -I consent Universal Health Hub nurse to take pictures of the feet condition for records, documentation and technology advancement. Today's date *Submit