Client Agreement - Selectacare

Client Information

Client Name

Client first and last name

Date of Birth

Month/Day/Year

Phone Number

Address

Apt, suite, etc.

Country

City

State

Zip code

Entry and Code

What door do you enter through? If there is an entry code, what is it?

Parking?

Yes

Is there parking available?

Emergency Contact 1

Relationship

Name

First and last name

Home Phone Number

Cell Phone Number

Business Phone Number

Emergency Contact 2

Relationship

Name

First and last name

Home Phone Number

Cell Phone Number

Business Phone Number

Emergency Contact 3

Relationship

Your relationship to the client

Name

First and last name

Home Phone Number

Cell Phone Number

Business Phone Number

Care History and Information

Client History

Describe client\'s health background

Client Careplan Information

Please enter all details regarding the client careplan

Invoice Information

Name

First and last name

Address

Apt, suite, etc.

Country

City

State

Zip code

Phone Number

Document Review

I have received and reviewed the Fee Schedule

I have received and reviewed the Terms and Conditions

Terms and Conditions

Please confirm that you have reviewed the Selectacare Terms and Conditions as well as the appropriate Selectacare Fee Schedule by checking below. By submitting this form you are agreeing to all terms and conditions within these documents. Also you are confirming the information submitted within this form is accurate.

Signature

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