Incare Home HealthCare : Home Health Referrals

Home Health Referrals

InCare Home Healthcare, Inc. would appreciate the opportunity to provide you with our professional care. If you or someone you know needs Home Healthcare Services, please complete the form below and we will see if you qualify for the benefits.

How did you here about us?
Please provide your contact information below and tell us about the patients home care needs so we can respond quickly to your inquiry.
The inquiry is for:
First Name:
Last Name:
Email:
Street Address:
Address Cont.:
City:
State:
Zip:
Home Phone:
Work Phone:
Best time to be reached:
Questions:
Patient Information:
Patient’s Name
Has or is this patient receiving home healthcare services?
Patient Screening:
Use Telephone	Yes No
Get out of bed unassisted	Yes No
Walk Unassisted	Yes No
Drive a motor vehicle	Yes No
Do there own grocery shopping	Yes No
Pay their own bills	Yes No
Prepare there own meals	Yes No
Do there own laundry	Yes No
Dress and undress themselves	Yes No
Follow medical directions	Yes No
Have prescription medications	Yes No
Have diabetes	Yes No
Receive home health care services	Yes No
Have a physician	Yes No
Bath themselves	Yes No
Have any other medical conditions	Yes No

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