Contact Information

Name(required)

Email(required)

Primary phone(required)

Other phone

Best time to contact you

Address

City

Postal Code

Information request is on behalf of:

What is the age of this individual?

In what area does this person live?

When is care needed?

What services are required (please check all that apply)

Nursing

• Medical care
• Health care management/training
• Medication administration

Personal Care

• Assistance getting dressed/undressed
• Help with bath/washing hair/shaving
• Assistance using commode
• Assistance with incontinence products
• Mask fit testing

Homemaking

• Light cleaning
• Laundry
• Shopping
• Running errands
• Escort to appointments/events
• Meal preparation
• Companionship

Caregiver Support

• Personal care and homemaking services on a short-term or as needed basis

Wound Care

• Specialized nursing care

Foot Care

• Specialized nursing care

Immunization

• Flu and hepatitis clinics

Corporate Wellness

• Blood pressure
• Blood glucose
• Cholesterol monitoring
• Health education

Other:

Uncertain

Where did you hear about Canada Health & Home Care Inc.?

Select all that apply.

Google

Yahoo

MSN

Other search engine

Yellow Pages on line

Yellow Pages print

Family

Friend

Health care professional

Brochure

Other: