Client Application for Non-Medical Home Care Full Name Date of Birth Age Gender MaleFemale Address City/State/ZIP Phone Email Emergency Contact Contact Name Relationship Phone Alternate Phone Physician Information Primary Care Doctor Phone Hospital Preference Health & Support Information Do you currently receive medical care? YesNo Allergies Medical Diagnoses (reference only) Do you use any of the following? WheelchairWalkerCaneOxygenOther Do you need help with (check all that apply) Bathing/GroomingDressingToiletingWalking/TransfersMeal PreparationLight HousekeepingTransportation/ErrandsCompanionshipMedication Reminders Service Preferences Preferred Days Preferred Times Start Date Requested Waiver & Acknowledgment I understand that B & C Home Care Services provides non-medical home care only. Staff do not provide medical treatment, skilled nursing care, or medication administration. In case of emergency, 911 will be called. I agree to provide accurate information and release B & C Home Care Services from liability for health issues beyond the scope of non-medical care, except in cases of proven negligence. Client/Representative Signature Date Agency Representative Signature Clear Date
