The one paying for the appointment
The loved one at Norwood LTC receiving the foot care
– 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 $65 invoice for the regular footcare appointments; $5 additional for finger nails; $5 for PGT administration fee (only PGT cases)
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
Clear Signature
Signature of of PoA