Client Information

Full Name is required.
Please provide a valid date of birth.
Phone Number is required.
Please provide a valid email address.
Home Address is required.
City is required.
required
Zip Code is required.
Emergency Contact Name is required.
Emergency Contact Phone Number is required.
Relationship to Client is required.

Service Information

Please select at least one option.
Other Services is required.
Please provide a valid service start date.
Please select at least one option.
Pick-up Address (if transportation) is required.
Destination Address is required.

Medical & Mobility Information

Please select at least one option.
Any medical conditions we should be aware of? is required.
Allergies is required.
Special Instructions is required.

Payment Information (Private Pay)

Please select at least one option.
Other Method is required.
Billing Contact (if different from client) is required.

Consent

You must agree to the terms before submitting.
Signature

Clear Signature

Draw your signature above
Date is required.
Instructions:
• Use your mouse or finger to sign
• Sign clearly within the box
• Click "Clear" to start over

Private Pay Service Agreement (Contract)

Service Agreement

This agreement is between Restoration Health Services- and the client listed above for private pay services.

  1. Services

    Restoration Health Services agrees to provide the requested services, including skilled and non-skilled care such as nursing services, companionship, assistance with activities of daily living, and other supportive care as scheduled.

  2. Payment Terms

    All services are private pay and are not billed to insurance.

    • Payment is due prior to or at the time of service unless otherwise agreed.
    • Accepted payment methods include credit/debit cards, cash, check, or electronic payment.
  3. Cancellation Policy

    Clients must provide at least 24 hours notice to cancel or reschedule services. Failure to provide notice may result in a cancellation fee.

  4. Client Responsibilities

    The client agrees to:

    • Provide accurate health and mobility information
    • Maintain a safe environment for staff
    • Treat staff respectfully
  5. Limitation of Services

    Services provided are non-medical unless specifically stated otherwise. Staff do not perform medical procedures unless licensed and contracted to do so.

  6. Liability

    Restoration Health Services- is not responsible for delays due to weather, traffic, or circumstances beyond reasonable control.

Agreement

By signing below, the client agrees to the terms of this service agreement.

Client Name is required.
Client Signature

Clear Signature

Draw your signature above
Date is required.
Instructions:
• Use your mouse or finger to sign
• Sign clearly within the box
• Click "Clear" to start over
Company Representative is required.
Please provide a valid date.

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