Please enable JavaScript in your browser to complete this form.Consent Date *PoA Name – The one paying for the appointment *The one paying for the appointmentName of loved one at Scarborough Retirement Residence *The loved one at Scarborough Retirement Residence receiving the foot care – I consent to the Universal Health Hub nurse to provide footcare every 6 to 8 weeks – 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 nailsHow would you like to pay after the service?Credit Card / Debit CardInterac Email TransferYour loved one will pay cash at the appointmentCheque send email transfer to INFO@UNIVERSALHEALTHHUB.CA No password is required Name on Credit Card *Card Number *CVV Number *Card Expiry Year *Card Expiry Month * Mail cheque to our Office Address : Suite#500, 7030 Woodbine Ave, Markham, ON L3R 6G2 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 – The one paying for the appointment * Clear Signature Signature of of PoASubmit