This Form cannot be submitted until the missing
fields (labelled below in red) have been filled in
YOUR CONTACT INFORMATION
Please note that all fields followed by an asterisk must be filled in.
Country United States Canada ---------------- Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribadi North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Federated States of Micronesia Moldova Monaco Mongolia Montserrat Morocco Montenegro Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda S. Georgia and S. Sandwich Isls. Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam US Virgin Islands Wallis and Futuna Islands Western Sahara Yemen Yugoslavia (former) Zaire Zambia Zimbabwe
Loved One's Name, First*
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
Check Blood Sugar
Check Blood Pressure
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
IF NOT IN EASTERN STANDARD TIME ZONE THEN PLEASE GIVE THEIR RELEVANT TIME ZONE*
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
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?*
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 Phone Number(s)*
Second Contact Name*
Second Contact Phone Number(s)*
Third Contact Name
Third Contact Phone Number(s)
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
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 *
Typing name verifies signature*
Love One’s Name *