Domiciliary Care Agency Booking Application Form

Client Information:

Full Name: _______________________________________________________

Date of Birth: ____/____/____

Gender: [ ] Male   [ ] Female   [ ] Other

Address: _______________________________________________________

City: _____________________ Postal Code: ________________

Phone Number: _______________________

Email Address: _______________________

Emergency Contact Name: _______________________
Emergency Contact Phone: _______________________

Preferred Language: _______________________

Care Needs:

Type of Care Needed: [ ] Personal Care   [ ] Medication Management   [ ] Companionship
[ ] Meal Preparation   [ ] Housekeeping   [ ] Health Monitoring   [ ] Other (please specify) ________________

Frequency of Care: [ ] Daily   [ ] Weekly   [ ] As Needed   [ ] Other (please specify) ________________

Preferred Care Schedule: ____________________________________________

Health Information:

Medical Conditions: ________________________________________________

Allergies: _______________________________________________________

Current Medications: _______________________________________________

Mobility Assistance Needed: [ ] Yes   [ ] No

Assistance with Activities of Daily Living: [ ] Bathing   [ ] Dressing   [ ] Grooming
[ ] Eating   [ ] Mobility   [ ] Toileting

Additional Information:

Preferred Caregiver Gender: [ ] Male   [ ] Female   [ ] No Preference

Cultural or Religious Preferences: ____________________________________

Additional Preferences or Requests: ___________________________________

Consent and Authorization:

I hereby authorize Premium Care Provider to use the provided information for the purpose of arranging domiciliary care services. I understand that the information provided will be kept confidential and will only be shared with authorized personnel for care-related purposes.

Signature: _____________________________    Date: ____/____/____

Declaration:

I declare that the information provided is accurate and complete to the best of my knowledge.

Signature: _____________________________    Date: ____/____/____

Emergency Contact Information:

Emergency Contact Name: _______________________

Relationship: _______________________

Phone Number: _______________________

Submit Your Application:

Please return this completed application form to Premium Care Provider via:

- Email: [Your Email Address]
- Fax: [Your Fax Number]
- In-Person: [Your Business Address]

Upon receiving your application, our team will contact you to discuss your care needs and arrange an assessment.

For Office Use Only:

Date Received: ____/____/____

Assigned Care Coordinator: _______________________

Assessment Scheduled: [ ] Yes   [ ] No

Comments: _______________________________________________________

__________________________________________________________________

Thank you for choosing Premium Care Provider. We look forward to providing you with exceptional care services.

[Your Business Name]
[Your Business Address]
[Your Phone Number]
[Your Email Address]
[Your Website URL]