LinkCo Enrollment Form

Enrollment Form

Kindly fill this form, sign and return with any attachments to LINKCO via email(admin@linkcohealth.com)
PERSONAL DETAILS
Who will be receiving the service?

SelfSomeone else
Title
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date*

MonthDayYear
Contact Details Person Completing Form or Responsible Party

Request copy of POA to admin@linkcohealth.com
Name*

First NameLast Name
Home Telephone*
Mobile
Do you have a valid email address?*

YesNo
Email*
example@example.com
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Living Situation (E.g. Do you live alone, or with friends, etc.)*
Where do you live?

Private HomeGated CommunityLong Term Care Facility or Apartment Building
Name of Facility/Apartment Building
Contact Details of Care Receiver
Date of Birth *
Name*

First NameLast Name
Home Telephone*
Mobile
Do you have a valid email address?*

YesNo
Email*
example@example.com
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Living Situation (E.g. Do you live alone, or with friends, etc.)*
Where do you live?

Private HomeGated CommunityLong Term Care Facility or Apartment Building
Name of Facility/Apartment Building
Identify Preferred Method of Contact*

PhoneEmailText
(Please note that we do not send correspondence via postal mail. All invoices, statements, receipts and miscellaneous information about your account and enrollment status is communicated digitally to the email address you have on file with us.)
Email*

By completing this form and clicking submit, you agree to receive occasional emails from LinkCo with updates on services, scheduled appointments, special offers, and promotions. You can unsubscribe at any time by clicking the 'unsubscribe' link at the bottom of our emails
SMS*

By enrolling and submitting this form, you agree to receive text messages from LinkCo related to services, scheduled appointments, special offers and promotions. Message & data rates may apply. Message frequency varies.
How did hear about us?*

Healthcare ProviderFamily or FriendSocial MediaGoogle SearchOther
Name of Provider
Social Media

FacebookLinkedInInstagramTwitterYou Tube
EMERGENCY CONTACTS (KINDLY PROVIDE AT LEAST 2)

	Name	Relationship	Phone
Emergency Contact 1
Emergency Contact 2
Emergency Contact 3

HEALTH DETAILS
Do you use any medical devices or equipment?*

YesNo
Please select

Collapsible wheelchairRollatorWalkerCaneOxygen TankOther
Do you have any health challenge or medical history you think we should be aware of?

YesNo
Kindly write details below
Other Details/Comments
Please read the service terms and conditions below:
Terms and Conditions*

PIRATING CLAUSE: Pirating practices or hiring the caregiver directly and secretly, inside this agreement is strictly prohibited. In the event that the undersigned, family, or anyone directly in relation to the client, secretly hires the agency’s caregiver in the absence of any written notice whatsoever, the action will be considered a breach of contract. A fee of $10,000 will be due based upon the financial losses to business and opportunities caused by the violation. A direct violation of this clause will be considered a breach of contract and will be given to our legal counsel for the due legal process of attention and collection.DIRECT HIRING CLAUSE: In the event that the undersigned desires to hire the agency caregiver directly within the said written agreement, the undersigned is required to give a written 7 days notice of the request addressed to the agency and agrees to the pay the referral fee equivalent to two (2) months pay or two (2) months service contract. Said payment will be given upon the direct hiring of the caregiver. If the undersigned fails to pay and remit the payment within seven (7) working days,the non-payment will be given to our legal counsel for the due legal process of attention and collection.INDEMNIFYING CLAUSE: The undersigned fully understands that the provider (a) is a non-medical provider, (b) is not licensed to perform medical services, and (c) the undersigned, indemnify, jointly, and severally hereby forever release, discharge, acquit, and forgive any and all claims, actions, suits, demands, liabilities, judgment, and proceedings both at law and in equity, arising from the beginning of time to the date of termination of this agreement with the Agency Provider, such are caused directly by the negligent acts or omissions by the above items and “Services” and the “agency caregivers” and which result in bodily injury or property damage. This release shall be binding upon insured to benefit the parties, their successors, assigns and personal representatives.ATTORNEY’S FEES: In any cases of any litigation, in prevailing party the “Agency Provider” shall recover the cost and attorney’s fees arising from any lawsuits brought against the agency.Payment and Termination of Services: Payment is due at the time services have been rendered unless other arrangements have been made. Therefore, we reserve the right to suspend or discontinue services for non-payment of an account balance. You acknowledge that a valid credit card must always remain on file unless other arrangements have been made. Failure to do may result in your account being deactivated at our discretion.Cancellation Fee and Policy: A cancellation fee of $55 will be charged for all scheduled appointments not cancelled at least 1 business day before the scheduled appointment.Membership Fees Refund Policy: Should you choose to become a member whether you select the month to month or annual option membership fees are non-refundable. Membership pricing is subject to change and without notice.Acknowledgement of Appropriateness of Services: Please acknowledge that you can sit, walk and stand with minimal assistance and understand LinkCo health workers cannot carry or lift clients and do not provide personal care services, which include but not limited to bathing, grooming, toileting, dressing or feeding. Clients that are wheelchair bound must be able to self-transfer in and out of a non-wheelchair accessible vehicle using a transfer board or other equipment that can be stowed away safely in a regular vehicle during transport.Pricing: Current pricing as of 1/1/2025 is listed below but subject to change at any time and without notice. We offer two different pricing options. Based on how often you intend to use our services will help to determine the best option for you. If you intend to use our services quite frequently each week or month then we recommend becoming a member as you will receive a discount on services. If you plan to only use services occasionally then becoming a member wouldn’t be the best option. Our membership rate is twenty-eight dollars per hour, and we do have a 2-hour minimum requirement. There is an annual membership fee that can be paid monthly or annually. The annual membership fee is three hundred dollars or if you choose to pay monthly it’s twenty-five dollars per month. Please note membership fees are non-refundable, so we suggest going with the monthly membership plan if you just want to try out the service. Our non-membership rate is forty-five dollars per hour.Medical Equipment and Devices: Please acknowledge that if you have a wheelchair, walker or rollator you understand these items must be collapsible and able to be stowed away safely in a non-wheelchair accessible vehicle such as a sedan, SUV or minivan.
LinkCo Community Guidelines

We want your LinkCo experience to be enjoyable and safe for everyone. These are some basic guidelines designed to ensure that riders and drivers have a five-star experience. Please take a moment to read as some rules may appear to be commonsense and others a pleasant reminder.

Respect each other. The golden rule applies treat others how you would like to be treated. Always try to be on time because nobody likes to wait. It’s common courtesy to not shout, swear or slam the car door. Any by tidying up after yourself and practicing good personal hygiene you’ll ensure the next person has a pleasant ride, too.

Safety first. Please ensure you follow the local law. Always buckle up when you get in the car. Drivers have a particular responsibility to keep to the speed limit, no texting while driving, always use a phone mount and never drive under the influence of drugs (e.g. prescribed or illegal) or alcohol.

No additional passengers are allowed in the vehicle only the authorized LinkCo companion driver and the rider(s) with an active LinkCo account.

Feedback is always welcomed. Whether you are a rider or driver please always share your honest feedback. It helps ensure that everyone is accountable for their behavior. This accountability creates a respectful environment for both riders and drivers. And if something happens during a ride whether it’s a traffic accident or an argument please report it to our LinkCo administrative office and customer support team (757) 802 – 4246.

REASONS RIDERS CAN LOSE ACCESS TO SERVICES

Damaging driver’s property.

Hitting or hurting a companion driver.

Use of inappropriate and abusive language or gestures.

Unwanted contact with the driver after trip is over.

Discrimination. We have a zero-tolerance policy towards discrimination of any kind. You will lose access to your account if you are found to have discriminated against drivers based on their race, color, religion, national origin, disability, sexual orientation, sex, marital status, gender identity, age or any other characteristic protected under applicable law.

Fraud or illegitimate behavior. For example, abusing promotions, collusion between rider and driver, disputing fares for fraudulent or illegitimate reasons or duplicate accounts.

If we are made aware of this type of problematic behavior, we may contact you, so we can investigate. Depending on the nature of the concern we may put a hold on your account during our investigation. If the issues raised are serious or a repeat offense or you refuse to cooperate you may lose access to LinkCo community.

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Enrollment Form

PERSONAL DETAILS

Contact Details Person Completing Form or Responsible Party

Contact Details of Care Receiver

EMERGENCY CONTACTS (KINDLY PROVIDE AT LEAST 2)

HEALTH DETAILS

CREDIT CARD AUTHORIZATION AND CONSENT FORM

CARD HOLDER INFORMATION

PAYMENT AUTHORIZATION