Registration and Job Description Form

Type of help
From
To

Contacts

Client Details

Full Name
Address
Postcode
Telephone
Email

Main Contact

Tick if next of kin
Full Name
Address
Postcode
Telephone
Email
Relationship

Any other contacts? (List names and numbers)

Next of kin (Please specify or tick above)

Full name
Address
Postcode
Telephone
Email
Relationship

Initial Costing To

Name
Address
Postcode
Telephone
Email

Invoice To

Name
Address
Postcode
Telephone
Email

Doctor

Name
Telephone
E-mail
Surgery Address
Do you have adequate motor and household insurance to 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:
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
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
  10 Hours
Residence:

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

Bedroom Bathroom Sitting Room TV

Amenities

Washing Machine
Fridge
Microwave
Smoke detector
Clothes Dryer
Freezer
Cooker

Housekeeping

Are the shops nearby?

Do you already have other help?
Cleaner
Gardener
Please state any additional help you require:

What meals need to be cooked
Breakfast
Lunch
Supper
And to what standard:
Client's Date of Birth
Client's physical history / condition:
Client's mental history:

Help with (please tick all that apply):

Getting up Going to bed Washing Bathing Showering (Un)Dressing
Help with  
Mobility
Transferring
Loo / Commode
Incontinence
Nightcare help
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.