PoA consent for regular foot care appointments at Lev Living

Consent Date *

PoA Name *

The one paying for the appointment

PoA Email to send invoice *

Name of loved one at Lev Living *

The loved one at Lev Living receiving the foot care

Room# at Lev Living *

How frequently you want the appointment?

every 6 to 8 weeks
once in 3 months
ONE time. i will then contact again whenever i need followup appointment

– I consent to the Universal Health Hub nurse to provide footcare
– I understand and appreciate that I may withdraw my consent, at any time by communicating with Universal Health Hub.
– I understand the purpose of this Consent and that I can refuse to sign it. I acknowledge that I am signing this consent willingly and voluntarily for my loved one and that my consent has not been obtained through misrepresentation or fraud.
-I will be paying the $55 invoice for the regular footcare appointments; $5 additional for finger nails; $5 for PGT administration fee (only PGT cases)

How would you like to pay after the service?

Credit Card / Debit Card
Interac Email Transfer
Preauthorized Direct Debit – I will give Void Cheque

Upload Void Cheque *

Drag & Drop Files, Choose Files to Upload

send email transfer to INFO@UNIVERSALHEALTHHUB.CA
No password is required

Credit Card to Save on File
I consent to the Universal Health Hub charging this credit card when my invoice is overdue for 15 days

Name on Credit Card *

Card Number *

CVV Number *

Card Expiry Year *

Card Expiry Month *

Credit Card Billing address POSTAL CODE *

Mail cheque to our Office Address : Suite#500, 7030 Woodbine Ave, Markham, ON L3R 6G2

Payor Name *

Payor Email *

Payor Phone Number *

Consent *

I consent to all of the above statements. I am okay to receive electronic invoices over email. I am okay to pay the invoices in 5 Business days after service is completed.

PoA Signature *

Clear Signature

Signature of of PoA