Gentle Nurture Senior Concierge & Post-Discharge Logistics
Client Intake Form Client Information
Name:
Date of Birth:
-
Mois
-
Jour
Année
2 digit month, 2 digit day, 4 digit year
Date
Address:
Phone:
Format: (000) 000-0000.
Email:
exemple@exemple.com
Emergency Contact:
Format: (000) 000-0000.
Services Requested
Companion &Concierge Visit Package
Safe Transition Package
Peace of Mind Monthly Plan
Concierge & Support Services
Free Consultation Preferred Date:
-
Mois
-
Jour
Année
2 digit month, 2 digit day, 4 digit year
Date
Time:
Heure minutes
AM
PM
AM/PM Option
Notes/Health Concerns:
Service Agreement
Gentle Nurture provides non-medical senior concierge and post-discharge logistics services. Services may include appointment coordination, companionship, grocery shopping, errands, home organization, wellness check-ins, technology assistance, transportation coordination, and resource navigation. No nursing, medical treatment, medication administration, or hands-on personal care is provided. Payment: Gentle Nurture is a
private-paid service
. Full payment is due before services are provided, unless other written arrangements have been made in advance.
Cancellation Policy: Please provide at least
24 hours' notice
if you need to cancel or reschedule an appointment. Late cancellations may be subject to a cancellation fee.
Client Initials:
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Authorizations Family Communication Authorized Contact:
Relationship:
Phone:
Format: (000) 000-0000.
Hospital:
I certify the information provided is accurate and agree to
receive non-medical concierge services. Client Signature:
Representative:
Optional
Gentle Nurture Senior Concierge & Post-Discharge Logistics HIPAA Authorization
I authorize Gentle Nurture Senior Concierge & Post-Discharge Logistics to communicate with the individuals and healthcare providers listed below regarding coordination of my non-medical services.
Authorized Person(s):
Relationship:
Phone:
Format: (000) 000-0000.
Expiration:
-
Mois
-
Jour
Année
2 digit month, 2 digit day, 4 digit year
Date
Client Signature:
Date:
-
Mois
-
Jour
Année
2 digit month, 2 digit day, 4 digit year
Date
Non-Medical Services Acknowledgment
I understand that Gentle Nurture provides non-medical senior concierge and post-discharge logistics services only. The company does not provide nursing care, medical treatment, medication administration, or hands-on personal care requiring licensure. In an emergency, 911 will be called.
Client Signature:
Client Initials:
Date:
-
Mois
-
Jour
Année
2 digit month, 2 digit day, 4 digit year
Date
Emergency Contact Information
Secondary Contact:
Phone:
Format: (000) 000-0000.
Phone:
Format: (000) 000-0000.
Preferred
Hospital:
Primary Physician:
Pharmacy:
Client Signature:
Date:
-
Mois
-
Jour
Année
2 digit month, 2 digit day, 4 digit year
Date
Privacy Notice & Client Rights Your information will be kept confidential except as authorized by you or required by law. You have the right to respectful, dignified, and confidential service.
Client Signature:
Date:
-
Mois
-
Jour
Année
2 digit month, 2 digit day, 4 digit year
Date
Emergency Information Preferred
Primary Physician:
Date:
-
Mois
-
Jour
Année
2 digit month, 2 digit day, 4 digit year
Date
Date:
-
Mois
-
Jour
Année
2 digit month, 2 digit day, 4 digit year
Date
Primary Emergency Contact:
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