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Arizona Assisted Living

Please fill out and send a form for each patient


PRE-SERVICE PROVIDER ORIENTATION

INSTRUCTIONS: This form is to be completed by the provider and the individual and/or responsible party receiving services prior to the initiation of services. A copy MUST be retained by the provider and a copy sent to the District Office. The provider must also ensure that a General Consent and Authorization form is completed and retained by the provider.
(By submitting the form below you are agreeing to Nhouse Inc. terms, conditions, policies and attesting to the factuality of the aforementioned statements and to the best of your knowledge you are law abiding in providing such information. Furthermore you are allowing nhousecare.com to electronically file this application, maintain and use its information without a wet ink signature.)

HOME CARE REPRESENTATIVE INFORMATION
If you are caring for the patient enter your information below



[text 594944]


No

CLIENT INFORMATION
Please fill out the patients information below











See page 4 for EOE/ADA/LEP/GINA disclosures
DD-097 FORFF (05-18) Page 2 of 4
HEALTH-MEDICAL
CURRENT MEDICATIONS AND SIGNIFICANT HISTORICAL ISSUES:



ALLERGIES TO:







SEIZURES:




ASSISTIVE DEVICES:





FOOD:








SPECIAL DIET



Beverges:










YesNo


YesNo


YesNo

Mobility
BALANCE WHILE STANDING:


YesNo



YesNo



YesNo



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Disclaimer

Please Read Before Continuing

N'House Inc. is an Arizona Approved Non Medical  Home Care Provider. As such, we are obligated to protect your data and privacy. By continuing you are agreeing to all of the N'house Inc. Policy's and Agreements. The information you give us will be shared with all the necessary Arizona State Government offices and Third Parties. Our goal is to help your caregiver succeed in providing you the very best service. Click on the Privacy and Agreements link at the bottom of any page on"nhousecar.com". If you have any questions, Contact Us.