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Post-Operative Recovery Care — Inquiry
Please provide the information below to request availability for short-stay post-operative recovery support. Submitting this enquiry does not confirm a booking.
1. Full Name
(First and Last Name)
[Text]
2. Phone Number
(Best number to reach you)
[Phone]
3. Email Address
[Email]
4. Are you completing this form as the client or on behalf of someone else?
☐ I am the client
☐ I am completing this form on behalf of the client
[Multiple Choice]
5. Type of Surgery
(Please specify the procedure)
[Text]
6. Date of Surgery
[Date]
7. Surgical Facility Name
[Text]
8. Location of Surgical Facility
[Text]
9. Is the client expected to be discharged as medically stable and ambulatory?
☐ Yes
☐ No
☐ Not sure
[Multiple Choice]
10. Desired Start Date for Recovery Stay
(Typically the day of discharge)
[Date]
11. Length of Stay Requested
☐ 3 days
☐ 4 days
☐ 5 days
[Multiple Choice]
12. Will transportation support be needed?
(Check all that apply)
☐ Pick-up after day surgery discharge
☐ Return transportation for first post-operative follow-up visit
☐ Transportation not needed
[Checkboxes]
13. Does the client have any mobility limitations we should be aware of?
(For example: walker use, assistance required, balance concerns)
[Short Text]
14. Please confirm the following acknowledgments
(Required)
☐ I understand this is a non-medical, short-stay recovery support service
☐ I understand this service does not replace medical care or home health services
☐ I understand availability is subject to review and confirmation
[Checkboxes — required]
15. Additional Information or Questions
(Optional)
[Long Text]
Assisted Home Care — Inquiry
Please provide the information below to request information or availability for residential assisted home care. Submitting this enquiry does not confirm admission.
1. Full Name of Person Completing This Form
[Text]
2. Relationship to Prospective Resident
☐ Self
☐ Family member
☐ Legal representative
☐ Other
[Multiple Choice]
3. Prospective Resident’s Full Name
[Text]
4. Primary Phone Number
(Best number to reach you)
[Phone]
5. Email Address
[Email]
6. Current Living Situation
☐ Living independently
☐ Living with family
☐ Currently in another care setting
[Multiple Choice]
7. Type of Placement Being Sought
☐ Short-term residential support
☐ Long-term residential support
☐ Not sure
[Multiple Choice]
8. Anticipated Move-In Timeframe
☐ Immediately
☐ Within 30 days
☐ 1–3 months
☐ Planning ahead
[Multiple Choice]
9. Level of Assistance Needed (Check all that apply)
☐ Bathing / hygiene
☐ Dressing / grooming
☐ Toileting
☐ Mobility / transfers
☐ Medication reminders
☐ Meal support
☐ Supervision / safety monitoring
[Checkboxes]
10. Mobility & Transfer Needs
(Please check all that apply)
☐ Requires two-person assist for transfers
☐ Requires Hoyer lift or mechanical lift
☐ Independent or one-person assist only
If two-person transfers or mechanical lift assistance are required, this service may not be appropriate.
11. Night-Time Safety
☐ No night-time wandering
☐ Occasional night-time wandering
☐ Frequent or unsafe night-time wandering
If frequent or unsafe night-time wandering is present, this service may not be appropriate.
12. Medical Stability
☐ Prospective resident is medically stable and under the care of a physician
☐ Not sure
13. Does the prospective resident require skilled nursing care or ongoing medical treatment?
☐ No
☐ Yes
☐ Not sure
If skilled nursing or medical treatment is required, this service may not be appropriate.
14. Preferred Room Type (Based on Availability)
☐ Private room
☐ Shared room
☐ Master bedroom (single occupancy)
☐ Not sure
15. Please confirm the following acknowledgments
(Required)
☐ I understand this is non-medical assisted home care, not a nursing home or medical facility
☐ I understand admission is subject to assessment and availability
☐ I understand pricing varies based on room type and Level of Care
[Checkboxes — required]
16. Additional Information or Questions
(Optional)
[Long Text]
