Caring Hands Agency
Medical & Emergency Information

Please print this form and complete

For immediate service this medical and Emergency Information page plus a copy of your check or credit card number for the $50 registration fee must be submitted by FAX to 214-520-1882.

Physician's Name ___________________________________________________

Physician's Address _________________________________________________

Physician's Phone Number ____________________________________________

Hospital Preference __________________________________________________

Hospital Address ____________________________________________________

Hospital Phone Number _______________________________________________

Special Instructions

My Care Recipient(s) have (has had) the following allergies or special needs:

Special considerations for a Caregiver coming to my home: (i.e. stairs, pets, transporting, etc.)

Will there be occasions when you will be in the home during a sitting? _________

Please be aware that transportation of a child/adult, light housekeeping, shopping, or parent in the home, additional fees will apply.