315 530 3023 CALL HOMEOUR TEAMSERVICESCAREERRESOURCESNEW CLIENTSCONTACT Providing Peace of Mind Peace at Homecare is always welcoming new clients. Our Values Build positive life experiences Deliver exceptional care with a tender heart Restore peace to our client's life 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. © Peace at HomeCare LLC. All Rights Reserved.
