Fill and submit this form online to book appointment for footcare by Registered Footcare nurse at home, hospital and RCC Not sure yet? Questions before submitting? Contact Us HERE 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 providedBilling address *address for invoiceContact Phone Number *Contact Email *For invoice and communicationService Requested *Only Foot Care (soak, nail clipping, medical foot care treatment, moisturizing and 10 mins. foot massage)Foot Care and added nail fingers trimmingDiagnosed with Diabetes/Borderline Diabetes? *Yes, Type 1Yes, Type 2NoDo you feel Numbness/Tingling/Burning sensation in your feet or toes? *YesNoAre you currently on Blood Thinners? *YesNoPlease indicate if you have, or have had, any of the following: *AIDS/HIVDepressionHigh Blood PressureRheumatic FeverAsthmaKidney ProblemsShortness of BreathBack ProblemsEpilepsyLiver ProblemsStomach UlcersBleeding DisorderGoutMultiple SclerosisStrokeCancerHeart AttackOsteoarthritisTuberculosisCholesterolParkinson’s diseaseCirculatory ProblemsHeart DiseaseRheumatoid ArthritisCerebral PalsyHepatitis A, B or CAdverse side effects or allergiesDo you smoke? *YesNoDo you consume alcohol? *YesNoAre you slow to heal after cuts? *YesNoSurgeries (Back, Hip, Knee, Ankle, Foot):Guardian Name *FirstLastGuardian Signature *Clear Signature-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. -Understand that I am financially responsible for all charges whether covered by my health insurance plan or not. I understand that service fees are payable at the time service is provided Today's date *Submit
