Caregiver Application | Gerocare App

Caregiver Application

Home Care Request

Please complete this form if you would like to book a certified Caregiver - a trained Home Care Attendant or a licensed health professional (doctors, nurses, physiotherapists etc.) for the delivery of home care services.

Your Details

Full name

Email Address

Phone number

Location (Town/City & Country)

Beneficiary Details

Beneficiary's Firstname

Beneficiary's Age

Beneficiary Gender

Beneficiary Phone No.

Beneficiary Email

Beneficiary's Current Address

Beneficiary State of Residence

City

Emergency Contact of the Client

Full name

Email Address

Phone number

Address

Proposed Caregiver Work Pattern(Please tick all that apply)

Live In - Full time (Caregiver lives with Client on full time)

Live In - Nights (Caregiver sleeps over with Client)

Live In - Weekends (Caregiver lives with Client only on weekends)

Live Out - Daily (Caregiver resumes every morning and closes in the evening)

Ad hoc (Caregiver attends to Client whenever required)

Others

Terms and Conditions

By clicking this, I agree that GeroCare can create an account for myself and the client so they can get reports and other information about care service to me on their platform.