New Client Registration Form
Client
Details:
Full Name
*
First Name
Last Name
Date of Birth
*
Client Phone Number
DNR
*
Please Select
Yes
No
Is there a copy of DNR in the house?
Please Select
Yes
No
Diagnosis / Medical Conditions
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Spouse (If applicable)
First Name
Last Name
Date of Birth
Client Phone Number
DNR
Please Select
Yes
No
Is there a copy of DNR in the house?
Please Select
Yes
No
Please Check all the following services you are needing:
*
Check-in/ Medication reminder
Showering/ hygiene
Transferring/ positioning
Grocery Shopping / Errands/ Dr. Appt.
Vital Sign Documentation
Bed/laundry Care
Meal preparation
Companion Care
Light housekeeping (basic care, no deep cleaning)
Other
Responsible Party - Emergency Contact
#1 Contact information
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Relation to Client
*
#2 Contact information
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relation to Client
Responsible party - Financial affairs
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Relation to Client
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Ok to receive invoice by email?
*
Please Select
Yes
No
How did you hear about us?
*
This is an application for Care Connect, Inc. to provide services. Our current Rates are $35/hr with a 4-hour time block minimum. Services provided will be billed out once a month to the responsible financial party.
Signature
Continue
Continue
Should be Empty: