Working Caregivers a source of help

Working caregivers know how hard it is to manage both outside work and caregiving, at the same time. It is just a part of family caring. We�ve been doing some research and we have found a way to help keep your loved one alive, out of the hospital emergency room and overnight stays as well as prevent nursing home admissions due to a person�s inability to take their medications properly, and other health regimens.

Together we can help maintain senior independent living. Give assurance that your family member is taking their medications while you are a working caregiver. There are other services that
'communicate'
With your loved one by electronic signals
or awaiting them to push a button (if possible).
Personal Voice can give you time for your self,
with the assurances that our calls to them will provide.
We can call for you while you are away.
For more information see the application page

fill the application

YOUR CONTACT INFORMATION

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name

Home Phone

Business Phone

Street Address

City

State/Prov

Zip/Postal Code

Country

E-mail Address*
E-mail Address*

Fax

Cell Phone

Loved One's Name, First*
Loved One's Name, First*

Midlle Initial

Last Name

Home Phone*
Home Phone*

Cell Phone

Work Phone

Street address

City

State/Province

ZIP

Country

Your relationship
to loved one

(Include your name for loved one
If you believe it can be helpful- their name for you)

Service Details
Exactly what you want us to do
(Please detail and please give dates and time for all outside activities).
UNLESS OTHERWISE REQUESTED, ALL DAILY CALLS TO LOVED ONE�S HOME
ARE MORNING, NOON-TIME AND EVENING.

Wake up call (If so when)

Check up call

Medications

Check Blood Sugar

Check Blood Pressure

Diet

Meals on Wheels

Vitamins, Fiber, Herb Supplements

Exercise, Walk, Dance, Tai Chi, Yoga. Martial Arts

Salon/ Hair care

Doctor Appointments,
Prescription Refills

Schedule confirmation
Nurse
Homemaker

Elder Care
Transportation

CHORES

Entertainment
Activities

IF NOT IN EASTERN STANDARD TIME ZONE THEN PLEASE GIVE THEIR RELEVANT TIME ZONE*
IF NOT IN EASTERN STANDARD TIME ZONE THEN PLEASE GIVE THEIR RELEVANT TIME ZONE*

Health Status/Medical Condition, if yes please give details below*
Health Status/Medical Condition, if yes please give details below*

Allergies to Drugs?

Medic-Alert ID Card?

Advanced Medical Directive
or Living Will?

Primary Physician�s Name

Phone

Address

If there is no answer on the phone, what warrants a health crisis (Emergency) in your estimation?*
If there is no answer on the phone, what warrants a health crisis (Emergency) in your estimation?*

Do they go out often?

Is it okay for them to not take any of their medication?*
Is it okay for them to not take any of their medication?*

If needed what emergency contacts do you wish us to make?
Their Local Emergency Contacts
*For EMS ("911")-need the loved one�s local emergency service number.
Do any of below have key access?
*(911) often varies according to counties and municipalities. *
If needed what emergency contacts do you wish us to make?
Their Local Emergency Contacts
*For EMS ("911")-need the loved one�s local emergency service number.
Do any of below have key access?
*(911) often varies according to counties and municipalities. *

First Contact Name *
First Contact Name *

First Contact Phone Number(s)*
First Contact Phone Number(s)*

Key access?

	Yes
	No

Second Contact Name*
Second Contact Name*

Second Contact Phone Number(s)*
Second Contact Phone Number(s)*

Key access?

	Yes
	No

Third Contact Name

Third Contact Phone Number(s)

Key access?

	Yes
	No

Special Services

	A Assistance with writing or form completion, compiling information
	B Bill sorting coordination of bills to benefits
	C Consulting with Medical Staff on a limited basis
	D Medical Billing Problem Resolution
	E Negotiating with insurance companies for eligible benefits

Special Services:Please give additional information. Commonly a limited power of attorney for the specific circumstance is required.

Do you have any power of attorney?

Optional Services,
Presidential greetings arranged
Gift Suggestions,
Book and Film Finding (Purchasing at additional cost)
Special discussions of Old Time Radio, early Films, early Television

Birthday/Anniversary reminders

Signature
By submitting this application, I affirm that the facts set forth in it are true and complete.
I understand that if I am accepted as a client, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate cancellation.
This application will be considered part of the agreement, which client and loved one should sign.
There is no independent investigation; actions are entirely based on loved one�s verbal answers.
At this time only loved ones whose primary language is English can be accommodated
For protection and assurances all calls between client, loved one and third parties are to be recorded.

Client �s Name *
Client �s Name *

Typing name verifies signature*
Typing name verifies signature*

Date*
Date*

Love One�s Name *
Love One�s Name *

Signature

Date

or homepage thanks.

for more caregiver info

Discount Coupons for Medical Supplies

If you want some outside help to come in click to this

Fast Feedback To Us
or Call 1-877-443-8636-1-USS-4-GET-ME-NOT

Please note that all fields followed by an asterisk must be filled in.

Only Form Out If you want us to reply. Thanks

First Name*
First Name*

Last Name

E-mail Address*
E-mail Address*

City

State/Prov

Zip/Postal Code

Country

Did you find what you are looking for?

	Yes
	No

What are you looking for

Are you a caregiver

	Working with a senior
	Seeking employment as a caregiver
	Working as a paid caregiver
	Needing additional income at home
	See our free webpage offer
	See our caregiver job description

Websites for general information on caregiving

	YES
	NO

Our best choices for websites on caregiving

	yes
	no

Legal issues about caregiving

	yes
	no

Financial issues about caregiving

	yes
	no

Spiritual concerns in caregiving

	yes
	no

Chat boards for caregivers

	yes
	no

Fast Feedback Form anything else?

Disclaimer
With the above adjacent services

Personal Voice Inc. can not and will not be held responsible for any failure on their part to achieve required results for any reason on behalf of client

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