Providing Peace of Mind

Peace at Homecare is always welcoming new clients.

New Client Information Form

Client Name

Date of Birth

Address

Phone Number

Email Address

Doctor Names, addresses, phone numbers (please indicate if primary care doctor, type of specialist, etc).

Hospital in Case of Emergency

Pharmacy

Current Medications

Uses Pillbox?

If so, where is it located?

Who fills it?

Power of Attorney Name / Phone

Health Care Proxy Name / Phone

Do they have a MOLST/DNR?

Where is it located?

Allergies (medication and / or food)

Primary Diagnosis

Secondary Diagnosis

Health History / Surgery

Contact Persons (name, relationship, phone number)

Likes and Dislikes (including food)

Major Concerns

Is there any special diet that we should be aware of, if so what?

How will we enter the house and lock up when leaving? (what door / garage, where is the key hidden, is there a lockbox and code, is there a garage code, any special parking instructions)

Please check off all that apply (check off even if we won't be helping and family helps)
CaneWalkerWheelchairAssistance with TransfersMeal PreparationAssistance with EatingGrocery ShoppingLaundryLight Housekeeping / Sheet changeHospital BedWound CareFall HistoryAssistance with Mail and PaperworkEscort to Appointments (doctor, hairdresser, etc)TEDS / Compression SocksMedication Reminders OnlyMedication AdministrationAssistance with Filling PillboxOxygenHearing AidsDenturesIncontinentWear Adult Briefs / PadsUses raised toilet seat or commodeAssistance with ToiletingAssistance with BathingAssistance with DressingAssistance with Oral CarePet Care

I certify that all the information submitted by me on this application is true and complete.
I agree

Signature (type your full name)

Today's Date

PEACE AT HOMECARE IS A CONCIERGE, BOUTIQUE-STYLE COMPANION HOMECARE AGENCY AND A LICENSED AND BONDED CAREGIVER EMPLOYMENT AGENCY.