PRIVATE HOME CARE

Our homecare companionship service is here to bring joy, support, and a sense of fulfilment to your daily life. For us to give your loved one the best attention possible, please give us a bit of information by completing the form below, we will be in contact to conduct a thorough assessment.

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DETAILS OF PATIENT

Gender
Full Name
Physical Address
Is the Postal/Billing Address the same as above?
Email

DETAILS OF PRIMARY CAREGIVER

Gender
Full Name
Physical Address
Is the Postal/Billing Address the same as above?

PATIENT REQUIREMENTS

Caregiver Shift
Do you require your carer to drive?
Are there any pets?

CANIDATE PREFERENCES

Language Preference
Will you consider someone who smokes?
Do you have any other requirements or notes for us to consider?

CLIENT ASSESSMENT

Emergency Contacts

PRE-EXISTING CONDITIONS

Does the patient have any allergies?

CURRENT MEDICATIONS

Are there any medication for us to know about?

PAST SURGERIES & HOSPITALISATIONS

Has the patient had any surgery or been hospitalised?

FAMILY MEDICAL HISTORY

Is there family medical condition we should know of?

VITAL SIGNS

DECLARATION

Confirmation
(GDPR) General Data Protection Regulation

(POPIA) Protection of Personal Information Act, 2013

By providing information and making use of our services you consent to Sage Care Agency, being in possession of such information. This includes the use of the relevant apps. The Financial and/or Office Manager undertakes that all personal and confidential information will be processed lawfully and in a reasonable manner that does not infringe the privacy of you or your organization as the data subject. The processing is necessary and complies with an obligation imposed by law on us, the responsible party and the processing protects the legitimate interest of you, the data subject. Please note no personal information will be divulged to a third party unless required by law and or the data subject has agreed to divulge information in writing.

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