Intake Form

HIPAA Consent Form
I authorize Comfort Home Care to disclose medical and personal care information to:
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Signature

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Date

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Date

Emergency Plan
In case of an emergency, Comfort Home Care staff will:
- Contact emergency services (911)
- Notify the emergency contact(s) listed above
- Notify hospice nurses of any changes
- Follow agency protocols and document the incident
Preferred hospital?
Advance directives on file?

YesNo
I authorize Comfort Home Care to provide non-medical services as outlined. I have revieved and understand the terms of service.
Client signature

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Date

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Date
Representative name (if applicable)

First NameLast Name
Representatives signature

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Relationship
Should be Empty:

Client Information