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Avhomecare

Your Information:

First Name: *
Last Name: *
Address: *
City: *
State: *
Zip: *
Day Phone: *
Eve Phone: *
Cell Phone: *
E-Mail: *
Client Information: *
Relation to client: *


Client Information:

Client's Name: *
Client's Address: *
Clients City: *
Client's State: *
Client's Zip: *
Client's Day Phone: *
Client's Eve Phone: *
Cell Phone: *
Client E-Mail: *
Client Gender: *
MF
Client Age: *
Client Height: *
Client Weight: *


Assistance Required: (as currently known)

Medication Administered: *
YesNo
Medication Explain: *
Meal Preparation: *
YesNo
Meal Explain: *
Dressing/Grooming: *
YesNoSometime
Dressing/Grooming Explain: *
Transportation to Doctors/Relatives/Friends: *
YesNoSometime
Transportation Explain: *
Bathing or Showering: *
YesNoSometime
Bathing Explain: *
Toilet, Incontinence: *
YesNoSometime
Toilet,Incontinence Explain: *
Housekeeping, Laundry, etc.: *
YesNoSometime
Housekeeping, Laundry, etc. Explain: *
Do you have a pet(s): *
YesNo
Do you have pet(s) Explain: *
In door plant care?: *
YesNo
Current Living Situtation: *
At homeLive alone
Assisted Living Facility: *
HospitalNursing Home
Assisted Living Facility Explain: *
Walking Ability: *
Without Help
With CaneWith Walker
Wheelchair/Beddridden explain: *
Memory Loss: *
No
OccasionallyFrequentlyDementia diagnosisAlzheimer diagnosis
Memory Loss explain: *
Other Pertinent Medical Information?: *
Services Desired:

Home Care, Live-Out: *
4-6 Hrs Per Day6-8 Hrs Per Day
8-12 Hrs Per Day24 Hrs Per Day
Residential Care Facility: *
YesNo
Assisted Living Facility Explain: *
Monthly Budget-Amount Range *
Timeframe Service Required *
Immediately
Service Required Within: *  Weeks
   
Security Code: Security-Code
New Code?
Please enter: *
   
  Advice: Fields with * have to be filled.

We are committed to your privacy and will not share your information with any third parties. Alternatively, you can call us with this information above at the telephone numbers listed below. After the initial contact is made above of this on-line form, America's Home Care staff will call you and/or your family, for a in-home assessment to discuss the personal needs and wishes, which serve as a basis for your homecare personalized plan. This ensures that the caregiver can properly address your physical, social, emotional and financial needs. Once all the involved parties can agree on the proposed initial fees and terms, we will then determine a customized care plan. After a caregiver has been assigned to your loved one, our managers will follow-up with personal, unannounced home visits and phone calls to ensure that the quality of care meets your expectations.