Caregiver Services Request Form
Abuja, Enugu and Lagos Residents.
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Client's Primary Contact Information
Primary Contact Information
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First Name
Last Name
Phone Number- Primary Contact (Whatsapp contact)
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Area Code
Phone Number
Phone Number- Primary Contact
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Area Code
Phone Number
Email- Primary Contact
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example@example.com
Tell us about the potential client
Past Medical History
High Blood Pressure
Diabetes
Stroke
High Cholestrol
Recent Surgery
Arthritis
Reflux
Cancer
Sickle Cell Diseas
Heart Disease
Asthma
Congestive Heart Failure
COPD
Seizures
Dementia
No Medial History
Other
Please tell us about other medical conditions
Which of the following services will be needed for the Client?
Multiple Selection is available
Caregiver Skills Needed
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Vitals Signs Checks
Glucose Check
Assisting with Personal Care
Bed Bath
Toileting
Safe Client Mobility
Fall Risk
Pressure Injury Risk (Skin Breakdown)
Feeding
Childcare- Child with chronic condition
Care of clients with change in Mental Status or maybe forgetful
Pad change
Other
Please provide additional information that helps us determine the client's specific needs. Indicate if you want a male or female Carer or any available gender.
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How did you hear about us?
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Word of Mouth
Instagram
Facebook
Flyer
Referral
Hospital
Doctor
LinkendIN
Email Newletter
Youtube
Search Engine
Other
Notes
Feeding of Caregiver is provided by the family. This applies to all live in shifts.
One of our Registered Nurse(RN) will conduct an initial home visits for (all applicable package) with subsequent monthly home visit once every month with a weekly follow up on the Caregiver via phone Call.
Caregiver will document daily clients activities.
Additional Information
Date
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Primary Contact's Signature
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Our Services
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Registration Fee
Covers home assessment, plan of care and caregivers background checks.
20,000.00
NGN
Notes
DAY SHIFT: Monday to Friday, 8 am to 5 pm.
SLEEPING NIGHT SHIFT: Monday to Friday, 5 pm to 8 am.
WAKING NIGHT SHIFT: Monday to Friday 5pm to 8am.
LIVE IN SHIFT: (2 carers on Rotation) 7 a.m. to 9 p.m daily. Services include feeding of carer by the family.
LIVE IN SHIFT: Monday 8am to Friday 5pm (1 carer). Services include feeding of carer by the family.
This is our basic fee…subject to change based on clients' residential location and Care needs. Which Shift do you want
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DAY SHIFT for 6,500 naira daily.
SLEEPING NIGHT SHIFT for 6,500 naira daily.
WAKING NIGHT SHIFT for 7,500 naira daily
LIVE IN SHIFT (All day) for 7,000 naira daily.
LIVE IN SHIFT (Monday 8am to Friday 5pm) 7000 naira daily.
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