Please enable JavaScript in your browser to complete this form.Consent Date *PoA Name *The one paying for the appointmentPoA Email to send invoice *Name of loved one at Amica Unionville *The loved one at Amica receiving the foot careHow frequently you want the appointment?every 6 to 8 weeksonce in 3 monthsONE time. i will then call again whenever i need followup appointment – 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 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 -I consent Universal Health Hub nurse to take pictures of the feet condition for records, documentation and technology advancement.How would you like to pay after the service? *Credit Card / Debit CardInterac Email TransferPreauthorized Direct Debit – I will give Void ChequeUpload Void Cheque * Click or drag a file to this area to upload. Name on Credit Card *Card Number *CVV Number *Card Expiry Year *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 PoASubmit
