Service Consent Form
This is for current Resident or authorized use only. If you are a resident, family member or Authorized Resident Representative, you may provide consent for providing services to residents here by submitting this form. The form is strictly confidential and only used by staff on a need to know basis. There is no ability to auto-complete or query the system, and entries are taken as is. Information is privately held in confidence and matched with residents to the best of our ability, after which, our staff member is sent the form to adjust her performable resident services. Note: the security of your information is important to us, which is why we encrypt our site with SSL technology via hosting. Please read our Privacy Policy to read more if you have any privacy concerns.
Enter Room Number
Check services allowable to be performed (leave blank if service(s) allowable at anytime):
I hereby acknowledge by submitting this form, I am submitting an electronic signature which provides consent to the Contractor, Smartset Mobile Hairdressers LTD., to continually submit and claim invoices for services delivered to the Resident to the Facility for payment using the Resident’s Trust Account or cash until otherwise notified.
I decline Smartset Mobile Hairdressers LTD. to provide services to the Resident at the Facility above unless otherwise notified.