Services for Clients

Registration and Job Description Form

Red-bordered items are required.


Type of
Help		   From
To

Contacts

Client Details

Full Name
Address
Post Code
Telephone
E-mail

Main Contact 

Full Name
Address
Post Code
Telephone
E-mail
Relationship

Any Other Contacts?
List names and numbers:

Next of Kin (please specify or tick above)

Full Name
Address
Post Code
Telephone
E-mail
Relationship

Initial Costing To

Name
Address
Post Code
Telephone
E-mail

Invoice To

Name
Address
Post Code
Telephone
E-mail

Doctor

Name
Telephone
E-mail
Surgery Address

Do you have adequate motor and household insurance ro cover a live-in care staff?

We should be very much obliged if you would tell us how you heard about Oxford Aunts Care:

Job Description

Qualities and experience expected from carer:

Age range preferred:   Must the carer be a non-smoker:

Must the carer be able to drive:   If yes, will you provide a car:

What type of car will it be:
Age limit (if any) for car insurance:
Can the car be used for the carer's time off:

Public transport available:

Does anyone else live in the household:

Does anyone living in or visiting the household smoke:

Pets in household:

Time off allowed with pay and who covers it:

  3 hours 10 hours
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Residence:   If other, please specify:

Own accommodation with food offered: (please tick all that apply)

     

Amenities

Washing machine    Clothes dryer
Fridge    Freezer
Microwave    Cooker type
Smoke detector    

Housekeeping: are the shops nearby: if not, specify shopping arrangements below:

Do you already have other help?

Cleaner
- How often
Gardener
- How often
Please state any additional help you require:

What meals need to be cooked:

  Approx. Time (or n/a) And to what standard:
Breakfast
Lunch
Supper

Client's Date of Birth

Client's physical history / condition:
 Client's mental history:

Help with (please tick all that apply):
         

Help with  Additional requirements (below if applicable):
Mobility > Assistance ; Aids
Transferring > Assistance ; Aids
Loo / commode > Assistance during:  
Incontinence > Aids    

Nightcare help  
for         Other

Medication  
    Any special dietary notes:
Diet preferred
Any allergies

Please now check over everything you have entered into the form and make sure it is as complete as possible.  When you are ready, click Send below.

 

Footnote.