Aegis Royal Care – New Client Inquiry Form
Compassionate In-Home Support for Seniors, Adults with Disabilities, and Families
Patient Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Relationship to Patient
Self, Daughter/Son, Spouse, Friend, Other
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Start Date
-
Month
-
Day
Year
Date
Which of the following services will be needed for the patient?
Multiple Selection is available
What Kind of Help is Needed?
Bathing or getting dressed
Memory or dementia support
Help with meals or cooking
Incontinence care
Medication reminders
Errands or appointments
Light cleaning or laundry
Companionship
Mobility assistance (walking, transfers, etc.)
Other
How Often Do You Need Help?
A few hours a day
Full days (6+ hours)
Overnight care
24-hour care
Not sure yet – would like guidance
Mobility Status:
Walks independently
Uses wheelchair
Uses walker or cane
Bed-bound
Needs assistance moving around
Any Medical or Mental Health Conditions We Should Know About?
Do You Have Any Support at Home Now?
Yes
No
If Yes (Please describe): _______________________________________
How Will Services Be Paid?
Private Pay
Long-Term Care Insurance
Not sure yet – need help figuring it out
Additional Information
Patient/Family Signature
Date
-
Month
-
Day
Year
Date
Submit
Submit
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