Senior & Elder Care
Elder Care Services Agreement
Agreement for elder care and home health aide services covering care plan, schedule, duties, and emergency procedures. Two signers (caregiver and family_member).
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# Elder Care Services Agreement **Effective Date:** ___________ This Elder Care Services Agreement ("Agreement") is entered into by and between: **Caregiver/Care Provider:** ___________ ("Caregiver") **Family Representative:** ___________ ("Family Member") acting on behalf of the care recipient: **Care Recipient:** ___________ ("Recipient") ## 1. Care Recipient Information **Date of Birth:** ___________ **Address:** ___________ **Primary Physician:** ___________ **Physician Phone:** ___________ **Known Medical Conditions:** ___________ **Allergies:** ___________ **Current Medications:** ___________ **Mobility Status:** ___________ **Cognitive Status:** ___________ ## 2. Scope of Services The Caregiver agrees to provide the following services: **Care Level:** ___________
Fields (41)
effective date
date 路 required
caregiver name
text 路 required
family member name
text 路 required
care recipient name
text 路 required
recipient dob
date 路 required
recipient address
textarea 路 required
primary physician
text 路 required
physician phone
text 路 required
medical conditions
textarea 路 required
allergies
textarea
medications
textarea 路 required
mobility status
select 路 required
cognitive status
select 路 required
care level
select 路 required
services
textarea 路 required
excluded services
textarea
care schedule
select 路 required
specific hours
textarea 路 required
overnight
select 路 required
term
select 路 required
compensation
text 路 required
compensation basis
select 路 required
overtime
select 路 required
holiday pay
select 路 required
payment frequency
select 路 required
payment method
select 路 required
emergency contact 1
text 路 required
emergency phone 1
text 路 required
emergency contact 2
text
emergency phone 2
text
medical consent
select 路 required
medication management
select 路 required
transportation
select 路 required
mileage rate
text
background check
select 路 required
certifications
select 路 required
termination notice
select 路 required
governing state
select 路 required
caregiver signer name
text 路 required
family member signer name
text 路 required
relationship
text 路 required
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