Respite Registration From

PATIENT DETAILS

Date

Patient Name

First

Last

Date of Birth

Sex

Cell Phone Number

Home Phone Number

Work Phone

Can We Leave a Message?

Home
Cell
Work

Please tick all that apply

Mailing Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Patient Current or Previous Occupation

Marital Status

MEDICAL INFORMATION

Primary Physician

Primary Physician Phone Number

Does the participant use assistive devices? (e.g., wheelchair, walker):

Level of assistance required (check all that apply) (copy)

Independent
Needs help with meals
Needs help with toileting
Needs help with mobility

Please tick all that apply

Allergies (if any)

Chronic Conditions or Diagnoses

Medications (list with dosages)

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name

First

Last

Contact Number

all INFORMATION Phone

Relation to Patient

PacificWest Home Care Inc.

Waiver & Release of Liability

Please read carefully before submitting your registration.

By submitting this registration form, I acknowledge and agree to the following:

I understand that respite care services provided by PacificWest Home Care Inc. are non-medical and may involve inherent risks, including the possibility of accidents, injury, or illness.
I release PacificWest Home Care Inc., its employees, contractors, representatives, and affiliates from any and all claims, demands, or liabilities arising from or related to the respite care services, except where caused by gross negligence or willful misconduct.
In the event of a medical or other emergency, I authorize PacificWest Home Care Inc. staff to contact emergency services and my listed emergency contact, and I accept financial responsibility for any costs associated with such action.
I have read, understood, and voluntarily agree to this Waiver & Release of Liability as part of my registration.

By submitting this form, I confirm my agreement to these terms.

PATIENT DETAILS

MEDICAL INFORMATION

EMERGENCY CONTACT INFORMATION

PacificWest Home Care Inc.

Waiver & Release of Liability

Trusted In-Home Senior Care: Surrey, Langley, North Delta

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