PATIENT INFORMATION

Title

Patient Name *

First

Last

Gender *

Room No (if applicable)

Approx age in years *

Service Address *

address where service will be provided

Contact Phone Number *

Contact Email *

For invoice and communication

Diagnosed with Diabetes/Borderline Diabetes? *

Currently on Blood Thinners?

Please indicate if you have, or have had, any of the following: *

slow to heal after cuts? *

any past foot problems or feet surgery? *

Service 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 $10

do you have Shellac on nails ? *

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 Name *

-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.
-I understand that I am financially responsible for all charges whether covered by my health insurance plan or not.
-I consent Universal Health Hub nurse to take pictures of the feet condition for records, documentation and technology advancement.

Today's date *