Consultation

GETTING TO KNOW YOU BETTER

Please fill in all information as accurately as possible. The information you provide will assist informulating a complete health profile. All information will be kept confidential.

First Name

Last Name

Date of Birth

Email Address

Address

City

Province

Postal Code

Home Phone

Cell Phone

Work Phone

Emergency contact

First Name

Last Name

Relationship

Home Phone

Cell Phone

Work Phone

Email address

Do You Require House Keeping?

Yes No

Do You require meal Prep?

Yes No

Do You Require Personal Care Services?

Yes No

How many hours a day do you require Services?

Is there anything you would like to add?

Thank you for taking the time to answer these few but important questions, this will help give us a better understanding of the services you need.

Providing a SAFE and INTERACTIVE environment, at an AFFORDABLE cost. We also want to help alleviate the primary caregiver’s stress or burnout by giving you the security you need in leaving your loved ones with us through a well-thought-out care plan.

Nexgen Cares offers a unique and Innovative approach toward our client’s wellbeing and that of their primary care giver.

Consultation

GETTING TO KNOW YOU BETTER

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