Care Consultation Test Request a Care Consultation Please complete the form below and a member of the Tap’N’Care team will contact you. Contact Information First name * Last name * Email address * Phone number * Care Information Who needs care? * Please selectMyselfParentSpouse or partnerFamily memberFriendOther Client's address or location * What service do you need? * Personal Care / PSW SupportNursing Care - RPNNursing Care - RNCompanionshipPost-Hospital CareInjection / Medical Procedure at HomeRespite CareNot sure yetOther Care Needs Select all that apply. Bathing / HygieneDressing / GroomingToileting AssistanceMobility / TransfersFeeding AssistanceMeal PreparationLight HousekeepingLaundryGrocery Shopping / ErrandsCompanionship / Social InteractionDementia CompanionshipSupervision / Safety MonitoringMedication RemindersMedication AdministrationInjection SupportOther Please describe the care needs * Care Schedule Days or schedule required Preferred start date How soon is care needed? Please selectImmediatelyWithin 1 weekWithin 2 weeksWithin 1 monthJust exploring options Best time to contact you Please selectMorningAfternoonEveningAnytime Funding Information Is insurance or another funding program involved? Please selectYesNoNot sure Additional Information Additional information I consent to Tap’N’Care contacting me regarding this care request. I understand that this form should not be used for medical emergencies.
