My Elderly Parents

My Elderly Parents
Wellness Check Disclaimer Form
Your Personal Information

Thank you for choosing My Elderly Parents. Kindly fill this form to help us provide the best wellness check-in for your elderly ones.
Full Name *

First NameLast Name
Address (Home or Office) *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number
Please enter a valid phone number.

Elderly Person's Information

To ensure a safe and enjoyable check in, please provide the following information about the elderly person.
Full name *

First NameLast Name
Home address ( or the address where the team will come to)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
What are the goals you will like us achieve from this service ( e.g. emotional support, companionship, wellness etc. ) *
Are there any specific concerns or preferences we should be aware of? ( e.g. mobility issues, disabilities etc. )*
Is there any additional information or special request you'd like to share with us ?

Disclaimer for Wellness Check Services
1. Purpose of Service: The wellness check service provided by My Elderly Parents LLC is intended to ensure the safety, well-being, and general health of the client. The service includes a wellness check-in via phone, video call, or in-person visit to assess the client’s health, emotional state, and physical environment. This service does not include any medical diagnosis or treatment.

2. Non-Medical Service: The wellness check service does not replace medical care. Our staff or volunteers are not licensed healthcare professionals and cannot provide medical diagnoses, treatment, or advice. If any health concerns arise during the wellness check, clients or their caregivers are advised to contact a licensed healthcare provider immediately.

3. Consent to Receive Services: By signing this form, the client or their authorized representative consents to receive wellness check services from My Elderly Parents LLC.The client agrees that they understand the purpose and limitations of the wellness check service, and they have provided accurate information regarding their health and needs.

4. Confidentiality: All information shared during the wellness check will be kept confidential and used solely for the purpose of the wellness check service. We will not disclose any personal information without the client’s consent, except as required by law or in case of emergencies where the client’s safety is at risk.

5. Liability: My Elderly Parents LLC is not liable for any injuries, accidents, or health conditions that may occur during the wellness check process. Clients are encouraged to seek immediate medical attention if any health issues arise after the wellness check. The company is also not liable for any actions taken based on the information provided during the wellness check.

6. Emergency Protocol: In the event that an emergency is identified during the wellness check, our staff will contact emergency services (911) or the designated emergency contact as provided by the client. The client acknowledges that they or their authorized representative will be responsible for any further medical or emergency-related expenses.

6. Client Responsibilities: The client agrees to provide accurate contact information and to inform My Elderly Parents LLC of any changes in health status or emergency contacts. Clients must also cooperate with wellness check protocols and be available for scheduled check-ins.

7. Termination of Services: My Elderly Parents LLC reserves the right to suspend or discontinue services if the client is uncooperative or if it is determined that the service is no longer required or viable.
ACKNOWLEDGEMENTS AND SIGNATURE

I, the undersigned, acknowledge that I have read and understood the above disclaimer. I voluntarily consent to receive wellness check services from My Elderly Parents LLC and agree to the terms outlined above.
Client or Representative Name *

First NameLast Name
Signature*

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My Elderly Parents

Wellness Check Disclaimer Form

Your Personal Information

Elderly Person's Information

Disclaimer for Wellness Check Services