Service Agreement
Please review the Client Service Agreement, then complete and sign the request form below so our team can review your request for home care services.
Understanding Your Service Agreement
This page brings the Client Service Agreement and the service request form together. Read the agreement, follow the guide to complete each part of the form, then sign and submit online.
The agreement text on this page is the document you are agreeing to. The guide only explains how to fill in the form. If anything is unclear, please contact our team before you submit.
Read the agreement
Review all ten sections of the Client Service Agreement below.
Complete the form
Enter your contact details, the patient's details, the services you are requesting, and an emergency contact. Medical, insurance and upload sections are in the form too.
Agree and sign
Tick the agreement and privacy consent boxes, then sign in the signature box at the end of the form.
Submit
Select Request Home Care Services. A confirmation message appears on screen once your form has been sent.
Before You Begin
Having these details to hand makes the form quicker to complete.
Required in the form
- Your email address
- Your phone number
- Your preferred contact method
- Your emergency contact's relationship to the client
- Your emergency contact's phone number
Helpful to have ready
- The patient's name and date of birth
- The services and schedule you are requesting
- Diagnosis, medical conditions, medications and allergies
- Insurance provider, policy number, physician and hospital preference
- A photo or scan of any supporting document (JPG, PNG or GIF)
Please read the agreement in full before completing the form. The same agreement text also appears inside the form, just before the agreement checkbox.
Client Service Agreement
Thank you for choosing Grace Home Care Provider. We are honored by the opportunity to provide compassionate, dependable, and personalized home care services for you or your loved one.
Before we begin services, please carefully review the information below. By submitting this request, you acknowledge that you understand and agree to the following terms and conditions.
1. Request for Services
By completing this Service Request Form, you are requesting home care services from Grace Home Care Provider. Submission of this form does not guarantee immediate services. All services are subject to an initial assessment, caregiver availability, and approval by our care management team.
2. Personalized Care Plan
Every client receives an individualized care plan based on their specific needs, health status, personal preferences, and physician recommendations when applicable. Care plans may be updated as your needs change.
3. Caregiver Assignment
Grace Home Care Provider will make every reasonable effort to assign qualified caregivers who best meet your needs. Caregiver assignments may change due to scheduling, availability, emergencies, illness, or other operational requirements.
4. Scheduling
Requested schedules are subject to caregiver availability. We will work closely with you to provide services at your preferred times whenever possible.
5. Client Responsibilities
- Provide complete and accurate information.
- Notify us of any changes to medical conditions, medications, or emergency contacts.
- Provide a safe working environment for caregivers.
- Inform us immediately if scheduled services need to be changed or cancelled.
6. Privacy & Confidentiality
Grace Home Care Provider respects your privacy. Personal information collected through this form will only be used for evaluating, coordinating, and delivering requested services. Information is handled confidentially and shared only when necessary for providing care or as required by law.
7. Medical Emergencies
Grace Home Care Provider provides non-emergency home care services. If you or the client experiences a medical emergency, please call 911 immediately before contacting our office.
8. Communication
By submitting this form, you authorize Grace Home Care Provider to contact you by telephone, email, or text message regarding your care request, scheduling, service updates, and related communications.
9. Accuracy of Information
You certify that all information provided is accurate and complete to the best of your knowledge. Providing false or misleading information may delay or affect the provision of services.
10. Consent & Acknowledgement
By checking the agreement box below and signing electronically, you acknowledge that:
- You have read and understood this Service Agreement.
- You understand that submitting this request does not establish services until an assessment has been completed.
- You consent to Grace Home Care Provider contacting you regarding your request.
- You agree to the terms outlined above.
How to Complete the Form
The form is one page with the sections below, in this order. An asterisk (*) marks a field the form requires.
Client Information
Includes required fieldsThis section is about you, the person completing the form.
- Name: first and last name of the person completing the form.
- Email * and Phone number * are required. The phone field accepts numbers only, so leave out spaces, dashes and brackets.
- Preferred Contact Method * is required. Choose one: Phone, Email or Text Message.
- Address: street address, city, state and zip code.
Patient Information
Optional- Patient Name and Date of Birth. The date is entered in day / month / year order.
- Gender: Male, Female or Custom.
- Current Living Situation: choose the closest match, from Lives Alone to Hospital or Other.
- Relationship to Patient: Self, Parent, Spouse, Child, Guardian or Other.
Requested Services
Optional- Services: tick every service you would like to request. Fifteen options are listed, from Personal Care to Overnight Care.
- Preferred Schedule: Morning, Afternoon, Evening, Overnight or 24 Hour Care.
- Preferred Days: the drop-down accepts one day.
Medical Information
OptionalSections 5 and 9 of the agreement ask for complete and accurate information.
- Describe the Primary Diagnosis, Medical Conditions, Current Medications and Allergies in your own words.
- Mobility Status: Independent, Walker, Wheelchair or Bed Bound.
Emergency Contact
Includes required fields- Emergency Contact Name: first and last name.
- Relationship * and Phone Number * are required. The phone field accepts numbers only.
- Email Address: optional.
Insurance (Optional)
Optional- Insurance Provider, Policy Number, Primary Physician, Physician Phone Number and Hospital Preference.
- The Policy Number and Physician Phone Number fields accept numbers only.
File Upload
Optional- Upload one file that may help us evaluate care needs, such as an insurance card, physician orders or a medication list.
- The file must be a JPG, PNG or GIF image, up to 10 MB.
Agreement, Privacy Consent and Signature
Final stepSection 10 of the agreement explains what checking the box and signing electronically means.
- Tick I have read, understood, and agree to the Service Agreement. after reading the agreement above.
- Read the two privacy consent statements and tick them.
- Draw your signature in the Signature box with your finger, mouse or trackpad.
- Select Request Home Care Services to send the form.
Request Home Care Services
Complete the form below. Fields marked with an asterisk (*) are required.
In WordPress this area outputs
.This preview does not contain the form.
Need Clarification?
If you have questions about the Service Agreement or need help finding the relevant information, please contact our team.
Grace Home Care Provider provides non-emergency services. In a medical emergency, call 911 first.