Questions?
bobbie@saintsalivecares.com
Call: 478.885.9061

2002 City of Refuge Road
Culloden, GA  31016
 
 
Client/Guardian Information Form
 
Referred by

Friend    News Article     This Website    Others Phone Book Ad

Client Information
Name  : 
Age  : 
Date of Birth  :  DD-MM-YYYY
Email  : 
Physician’s Name  : 
Current Medications  : 
Guardian Information
Name  :
Relation to Client  :
Address  :
Phone No.  : Home :
Office  :
Cell     :
Type of Care Requested

Adult Day Care  In Home Care Assisted Living
Hospice Care     Respite Care  Skilled Nursing
Physical Therapy/Occupational Therapy Alzheimer’s Care Other
Physical History of Client/Diagnoses
Is Assistance Needed with any of the following?
Advanced Directives
Powers of Attorney for financial and medical
Wills
Trusts
Estate Planning
Choose all types of Financial/Medical benefits available to the client
Medicare
Medicaid
Pension
VA Benefits
Health Insurance
Long Term Care Insurance
Other
 
Note :
 “Client” is the person whom the care will be provided for.
 “Guardian” is the person who is responsible for the client.
Copyright © 2004, Saints Alive Cares, Inc. Care Options and Placement Management. All rights reserved.

DISCLAIMER: All information on this website is intended for your general knowledge only and is not a substitute for medical advice or treatment for specific medical conditions. We can not and do not give medical advice. The information contained in this online site is presented in summary form only and intended to provide broad consumer understanding and knowledge. The information should not be considered complete and should not be used in place of a visit, call, consultation or advice of your physician or other health care provider. We do not recommend the self-management of health problems.