Form

Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date

MonthDayYear
Date

Appointment

🌞 Comfort by Day Services

🌸 Standard Care Visits

Companionship, light housekeeping, meal prep, mobility help, reminders, family updates.)

$30.00 HOURS
Item subtotal:$0.00

🌸 ADL Support Care

(Bathing, dressing, grooming, toileting assistance.)

$35.00 HOURS
Item subtotal:$0.00

🧡 Southern Starter Bundle -$85

* 3 hours of ADL Care *Light Meal Prep * Quick Check in or Companionship

$100.00 HOURS
Item subtotal:$0.00

🌸 Sweet Sleep Overnight Care

(Overnight care from approx. 8:30 PM – 6:00 AM.)

$130.00 HOURS

🌸 Early Bird Mini Shift

(Early morning care from approx. 3:00 AM – 10:00 AM.)

$75.00 HOURS

🌸 Half-Day Respite Care

(4 hours of continuous daytime care.)

$120.00 Quantity

🌸 Full-Day Respite Care

(8 hours of continuous daytime care.)

$180.00 Quantity

💙 Comfort Combo — $250 Weekly A balance of daytime & overnight support all week.3 weekday mornings (3 hours each)1 overnight stayLight housekeeping, ADL assistance, meals, and laundry

$250.00 Quantity

🌸 Add-On: Extra Hour of Care

Add an additional hour to any care package.)

$25.00 Quantity

🌸 Add-On: Transportation/Errands

💲 $15 local (within 10 miles)💲 $25 extended (10–20 miles)

$15.00

	Miles	Price
Local (within 10 miles)		$15.00
Extended (over 10 miles)		$25.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00

🏡 Comfort by Day - Care Recipient Information Section

✍🏽 For the Care Recipient Information page:"Please complete the following information about the care recipient.Accurate details help us ensure proper care and successful scheduling. All fields are required unless otherwise noted."

1. Care Recipient Full Name
2. Care Recipient Date of Birth

MonthDayYear
Date
3. Care Recipient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
4. Primary Diagnosis or Medical Conditions*
5. Known Allergies? ➔ Example: Alzheimer's, Stroke Recovery, COPD, etc.*
If YES, open a text field: “Please list any known allergies”
6. Special Care Instructions / Behavioral Concerns ➔ Example: Wandering risk, needs assistance with transfers, etc.*
7. Specific Care Needs
Does the care recipient need mobility assistance? (
Help with medications?
Dietary restrictions? ( Please list if yes)
Any behavioral concerns or memory issues? (Explain)

I confirm that the information provided is accurate and I agree to Comfort by Day’s service terms and pricing.*

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🏡 Comfort by Day - Care Recipient Information Section