Patient-Enrollment

New Patient Enrollment

Life must be lived... Not spent!

Patient name

Last name

Patient address:

Village

Phone Number

Date of birth*

Current age*

Patient weight (pounds)*

Marital status (Adults Only)

Sex*

Taking any medications, currently?

Yes No

If yes, please list all. or None

Allergies

If yes, please let us know what or none.*

Have they been diagnosed?

If yes, please list condition

Skin condition*

Intact Dry/Fatigue Irritations (rash) Open World

If yes - Location

Is the Patient able to communicate?*

Yes No

Mental status (Check all options)*

Alert Oreinted Disoriented

Does the patient sleep well at nights?*

Yes No

Food / Meals... Eat or not eat etc.

Doctor's name: If none (Type N/A)*

Doctor's number: If none (Type N/A)*

Next of Kin name & address:

Address

Village

Next of kin contact*

Next of kin Email*

Who would be directly responsible for monthly billing? (Please specify name/s below)

Emergency contact:*

Last Name

Relationship*

Phone Number

Projected Start Date

Additional days or time needed. (None)

I hereby declare that the above made statements are true and correct to the best of my knowledge and belief, and any false information will or can lead to termination of contract.

How difficult was it to maneuver the form?*
Straight Forward*
Not Satisfied

yes No

Somewhat Satisfied

yes No

Satisfied

yes No

Difficult*
Not Satisfied

yes No

Somewhat Satisfied

yes No

Satisfied

yes No

Too long*
Not Satisfied

yes No

Somewhat Satisfied

yes No

Satisfied

yes No

Covered All bases*
Not Satisfied

yes No

Somewhat Satisfied

yes No

Satisfied

yes No

Prior to obtaining our services of home health care: I certify that i clearly understand the following: I choose to consult with Ace Adult & Kid Kare Services as a certified caregiver agency who conveys self-help information that people can use to enhance wellbeing. I affirm my right to self-health, and I take full responsibility for my healing process with his/her guidance and support.

I affirm that the responsibility is ours. I understand that ACE KARE does not provide legal medical services, but instead suggestions that I can choose to use for healing. ACE is not a licensed health care provider or medical doctor. ACE KARE do not diagnose, prescribe, or treat symptoms, defects, injuries or diseases. Please read and sign to acknowledge that you understand and agree to the above statements. You will not be acepted without these terms and conditions. Thank you!