Service and Information Request

Contact Information

Name(required)

Email(required)

Primary phone(required)

Other phone

Best time to contact youAnytimeMorningAfternoonEveningWeekend

Address

City

Postal Code

Information request is on behalf of:SelfSpouseChildFamily memberOtherFriend

What is the age of this individual?

In what area does this person live?BowmanvilleBramptonEast YorkEtobicokeLindsayMississaugaNorth YorkPeterboroughScarboroughTorontoYorkOther

When is care needed?As soon as possibleImmediatelyUncertain

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 Spectrum Health Care?

Select all that apply.

Google

Yahoo

MSN

Other search engine

Yellow Pages on line

Yellow Pages print

Family

Friend

Health care professional

Brochure