SHC Service Request
To ensure smooth communication, please actively check your phone and email for any messages from the SHC team.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Room Number (If Resident of Brookdale Senior Living)
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Service Type
Technological Assistance
Household Help
Other
Describe Service Request
Preferred Date and Time
How did you hear about us?
By submitting this form, I acknowledge and agree to the following terms:Assumption of Risk: I understand that there may be inherent risks involved in receiving services from Silver Heart Care, including transportation, physical assistance, and household activities. I voluntarily assume all related risks.Release and Waiver: I release and discharge Silver Heart Care, its officers, employees, volunteers, and agents from any claims or liabilities arising from my participation in their services, including any injury or damage, whether caused by negligence or otherwise.Indemnification: I agree to indemnify and hold harmless Silver Heart Care and its representatives from any claims or expenses resulting from my participation in their services.Medical Treatment: I consent to any necessary medical treatment and understand that I am responsible for the costs.By submitting this form, I confirm that I have read, understood, and agree to these terms.
Submit
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