Care Service Request

  • Care Service Request

    Home Care | Medical Escorts | Facility Staffing | Hospital Private Duty

  • Need care as soon as possible?

    Please complete this form so our team can quickly review your request and determine caregiver availability as soon as possible. Submission of this form does not guarantee service until C-Care confirms the booking by phone, email, or text. 

    Requests received using this form are priortized and will be responded to as soon as possible.

    For an immediate response or to speak with a C-Care representative, please call 416-724-2273, press #1. 

    For medical emergencies, please call 911 or go to the nearest emergency department.

  • How would you like us to contact you?*
  • Format: (000) 000-0000.
  • What service are do you requesting?*
  • What assistance is required? Select all that apply.
  • What type of Healthcare provider you are requiring?*
  • What type of Medical Escort you are requiring?
  • What type of Specialized Care are you requiring?
  • Are you requesting this service for:*
  • When do you need service to start?
  • How long do you anticipate the need for service?
  • Should be Empty: