Book Homecare Page

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Name *

First

Last

Age

Contact info (Phone number, Email) *

Emergency Contact (Name, Relationship, Phone number) *

Location *

• Living Situation (Apartment, house, etc.) *

Mobility (Independent, requires assistance with walking, bedbound, etc.) *

• Primary doctor name and contact information: *

• List of current medications: (Including dosage and frequency *

• Allergies: (To medications, food, other) *

• Medical conditions: (Diabetes, heart disease, dementia, etc.) *

• Dietary restrictions: (If any) *

• Special equipment used: (Walkers, wheelchairs, oxygen tanks, etc.) *

• Assistance with personal care: (Bathing, dressing, toileting, etc.) *

• Meal Preparation *

Grocery Shopping *

• Housekeeping: (Frequency and specific tasks) *

Laundry *

Transportation *

• Medication reminders: (Needed or not) *

• Companionship: (Desired level of social interaction)

• Specific preferences for caregiver (age, gender, experience, etc.) *

• Number of hours of care needed per day/week *

• Start date for care

• Hourly rate or salary expectations *

• Any other relevant information *

(+0023)-433-233-0234
medicdispatch@gmail.com