Selectacare Client Information | Personalized Care Details

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Client Details

Personal and contact information

First Name *

Last Name *

Preferred Name (optional)

Date of Birth *

Gender *

Male

Female

Other

Primary Language

Contact

Cell Phone *

Home Phone

Address

Address Line 1 *

Address Line 2 / Unit

City *

Province *

Postal Code *

Country *

Major Intersection

Access

Entry Instructions / Door Code

Parking Available?

Yes

Parking Instructions

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Emergency Contacts

At least one contact required · up to 3

🔒 At least one emergency contact is required. Contacts checked for care or billing decisions will be shared with our care team as per the privacy policy.

Contact #1

Full Name *

Relationship to Client *

Primary Phone *

Secondary Phone

Address

Authorized for Care Decisions?

Yes

Authorized for Billing Communication?

Yes

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Client History & Care Plan

Medical background, preferences & care notes

Client History Summary

Current Care Plan Details

Preferences (comfort, routines, cultural considerations)

Allergies

Physical Metrics

Height

Weight

Medical Directives

DNR Status

DNR Location

Home Environment

Smoking in Home?

Yes

Pets in Home?

Yes

Pet Details

Infection Control Concerns

Other Medical Notes

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Billing & Administration

Invoice preferences and financial contacts

Invoice Delivery Method

📧 Email

📬 Mail

Billing Contact Name

Billing Company / Organization

Billing Phone

Billing Email

Billing Address

Insurance Requirements?

Yes

Other Notes

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Terms, Conditions & Consent

Please read carefully before signing

Terms and Conditions

Accounts are interest free for 28 days from the invoice date, after which the interest rate shown on the statement will be applied.
If Selectacare is notified that the subscriber is in an emergency situation, I authorize them to arrange emergency care and Selectacare shall not be held liable for the consequences of such arrangements.
To protect the time and resources we invest in recruiting and supporting our caregivers, we ask that clients do not hire or engage any caregiver introduced by our agency for private employment outside of our services during the time you are working with us and for 12 months afterward. If you choose to hire a caregiver directly during this period, a placement fee of $5,000 will apply. This fee helps cover the costs of recruiting, screening, training, and supporting our caregivers.
Violation may result in charges equal to the Conversion Fee plus damages.
I have reviewed the Selectacare privacy policy and consent that care planning information to be shared with those contacts checked in section two.
Service can be cancelled 24 hrs. prior to the service time booked, will not be billed or charged to the client.
Client-related expenses will be invoiced unless paid for at the time.
If a worker is sent away before the end of the booked service, the client will be invoiced for the entire period to avoid penalizing the worker.
Statutory holidays will be billed at time and a half.
I have read the above as well as the current Selectacare fee schedule and brochure, and I am in agreement with all terms and conditions. I also give permission to phone the designated contacts should Selectacare deem it to be necessary.

Document Review

I have reviewed the Fee Schedule * In completing this form I am confirming all information provided is accurate and am agreeing to the above terms and conditions. *

Signature

Completed by: *

Relationship (if signing on behalf of client)

Date *

Signature *

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Client Information Form

Terms and Conditions

Document Review