GEL Home Health Care Services


	Service Request * denotes required fields

	* Salutation
	* First Name
	* Last Name
	City
	State
	* Primary Phone
	Secondary Phone
	* Email Address
	*When is the best time to contact you?
	What are the estimated days per week?
	What are the estimated hours per day?
	*Who is in need of Service?

	Please provide the desired location where the service(s) will be provided:
	*City:
	Zip:		State:

	Patient History Form the list below, (Please Select any conditions that patient has experienced in the past)

	Select All Alzheimer Anemia Autism Bedridden Breathing Tube Broken Hip Burn Victim Cancer Catheter Cerebral Palsy Dementia Diabetas Down Syndrome Vision Problems		Fall Risk Feeding Tube Hearing Problem Heart condition High Blood Pressure Hip surgery Incontinence Low Blood pressure Mental Retardation Multiple Sclerosis Prader-Willi Syndrome Schizophrenia Spina Bifida Stroke Wheel chair bound

	Needs Information From the list of choices below, which one best describes your primary needs:

	Select All Ambulation Companionship Dressing (Partial assistance) Dressing (Total assistance) Errands Feeding Injections Insulin shots Laundry Light Housekeeping Meal preparation Medication Administration Medication Assistance		Oral care Rehabilitative Care Shave Shopping (Accompanied) Shopping (Unaccompanised) Shower (Partial assistance) Shower (Total assistance) Skilled Nursing Care Supervision Toileting Transfer Wound Care

	Please select your preference for where care is to be provided:

	Select All In-Home Independent Living / Senior Community Group Home / Residential Care Home Counting Care Retirement Community Skilled Nursing Facility / Nursing Home		Rehab Adult Day Care Facility Hospital Not applicable to my request

	* What funding source will be the primary payer for the services?

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