Client Profile | Silver Home Care

1. CLIENT INFORMATION

Personal Information

Client Name

Date of Birth

Age

Gender

Contact Information

Primary Phone

Leave Message?

Yes No

Cell Phone

Can Text?

Yes No

Email Address

Can Email?

Yes No

Service Address

Street Address

City

State

ZIP

Township

County

2. CONTACTS & MEDICAL PROVIDERS

Primary Contact (Main person for day-to-day scheduling and routine care decisions)

Who is the primary contact?

Client Other

Full Name

Relationship

Phone

Email

Emergency Contact

Full Name

Relationship

Phone

Email

Medical Providers

Primary Doctor - Name

Primary Doctor - Phone

Skilled Nursing - Name

Skilled Nursing - Phone

Wound Care - Name

Wound Care - Phone

Hospice - Name

Hospice - Phone

Pharmacy - Name

Pharmacy - Phone

4. HOME INFORMATION

Home Type

Single Family Apartment Senior Housing Other

Living Situation

I live alone

If not, who lives with you?

Floor Level

First Floor Second Floor Other

Entry Instructions

Knock Doorbell Intercom / Call Box Lockbox

Code:

Where do we park?

Driveway On Street Parking Garage None Available

Pets

Yes, there are pets No pets

Pet Details (type, name, temperament)

Smoking

Yes, someone smokes No one smokes

5. PAYMENT & INSURANCE

Payment Source

CHC Veterans Private Pay LTC Insurance Other

MCO Name

MCO Member ID

Service Coordinator

Coordinator Phone

Medicaid ID

Medicare ID

Primary Insurance

Member ID

Client/Representative Signature

Sign here

Date

Important:

Please have the following ready for our visit:

Power of Attorney (POA) document (if applicable)
Current medication list
Photo ID
Insurance cards (Medicare, Medicaid, etc.)
Any recent hospital discharge instructions