Fill and submit this form online to book appointment for footcare by Registered Footcare nurse at home, hospital and RCC Don’t miss out on 10% OFF when you leave us a Google Review Not sure yet? Read testimonials and more about our services HERE. Still 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 (assessment, nail clipping, corn/callus/ingrown toenail treatment, moisturizing and 10 mins. foot massage)Foot Care and added nail fingers trimming for additional $5Diagnosed 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 PressureGoutBleeding DisorderCognitively declinedOsteoarthritisCirculatory ProblemsHeart DiseaseOther medical condition/sAdverse side effects or allergiesslow to heal after cuts? *YesNoany past foot problems or feet surgery? *YesNoPayor Name *I 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 Signature – one paying the invoice *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
