Qlaera - Companion Care | Alpha Release: Sign Up Form

1
Intake* This field is required.
2
Contact Preference
3
Please Click "Book" to select the best day and time for your initial call
4
Preferred Name
5
Why are you interested in this service? (Select all that apply)
6
How often would you like to receive check-in calls?
Daily
Weekly
A few times a week
Other
7
What time of day do you prefer to receive calls?
Morning
Afternoon
Evening
Other
8
What topics do you enjoy talking about? (Check all that apply)
Family and Friends
Hobbies and Crafts
Current Events
Books or Movies
Travel and Experiences
Memories and Life Stories
Other
9
Personal Interests and Preferences
Do you have any specific conversation preferences or topics to avoid?
Do you have any pets or hobbies you’d like to share about?
10
Health and Safety Considerations (Optional and confidential)
Do you have any health concerns or special needs we should be aware of during our calls?
Do you have any communication preferences (e.g., hearing difficulties, speech challenges)?
What would make this service valuable to you?
Do you have any expectations or specific goals for using our service?
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Emergency contact
Emergency Contact Name
Please Select
Please Select
Child
Brother / Sister
Parent
Relationship to You
Relationship to You: Other
Emergency Contact Phone Number
12
How did you hear about us?
13
Legal Acknowledgments
Please Select
Please Select
Yes
I understand that this service is not a replacement for medical or emergency services. (Checkbox)
Please Select
Please Select
Yes
Do you consent to receive calls, messages, or emails from our service?
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Terms and Conditions* This field is required.
15
If you would like to receive text message communication, text START, YES, to this phone number: 321-401-7856 from Solo Enterprize, LLC dba Qlaera You will be opt-in to text messages.

Message frequency varies and may include appointment reminders or service offers. Message and data rates may apply. You may opt out at any time by replying Reply STOP at any time to end or unsubscribe. For assistance, reply HELP or contact support at: 321-401-7856

See our Privacy Policy: https://www.qlaera.com/privacy-policy.html for details on how we handle your information
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Please verify that you are human* This field is required.
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