Customer Onboarding Form
1
Your Information
2
Parents' Residence
3
Parents' Information
4
Preventive Healthcare
5
Key Support Areas
6
Declaration
Title
*
Mr.
Mrs.
Ms.
First Name
*
Middle Name
Last Name
Mobile Number
*
Email
*
Country
*
Your Country
State
*
Your State
City
*
Your City
Address Line 1
*
Address Line 2
Pincode
*
Parents' Address Line 1
*
Parents' Address Line 2
Parents' Pincode
*
Parents' Country
*
India
Parents' state
*
Select
Parents' City
*
Select
Parents' home landline number
First Name of Parent
*
Middle Name of Parent
Last Name of Parent
Parent's Mobile Number
*
(Must be different from your mobile number)
Parent's Email ID
(Must be different from your email)
Parent's Date of Birth
Health Conditions
Hypertension
Diabetes
Arthritis
Cataract
CVD
Digestive Disease
Lung Disease
Osteoporosis
Kidney Disease
Liver Disease
Cancer
Anxiety
Depression
Dementia
Parkinson's Disease
Alzheimer's Disease
Others
Functional Capacity
Bedridden
Limited mobility to manage with support in the house
Can manage in the house without support, but needs support for outdoor activities
Can manage in the house and can manage basic outdoor activities
Fully active
Do you want to add another parent?
Yes
No
First Name of Parent
*
Middle Name of Parent
Last Name of Parent
Use same number as Parent 1?
Parent's Mobile Number
*
(Must be different from your mobile number)
Parent's Email ID
(Must be different from your email)
Parent's Date of Birth
Health Conditions
Hypertension
Diabetes
Arthritis
Cataract
CVD
Digestive Disease
Lung Disease
Osteoporosis
Kidney Disease
Liver Disease
Cancer
Anxiety
Depression
Dementia
Parkinson's Disease
Alzheimer's Disease
Others
Functional Capacity
Bedridden
Limited mobility to manage with support in the house
Can manage in the house without support, but needs support for outdoor activities
Can manage in the house and can manage basic outdoor activities
Fully active
Please tick which of the essential screenings have been undertaken already by the parent(s)
Lipid Disorder
Colorectal Cancer
Cardiovascular Screening
Osteoporosis
Diabetes - HbA1c
Breast Cancer
PSA
None
Please tick which of the essential vaccinations have been undertaken already by the parent(s)
Hypertension
Pneumococcal
Shingles
Tetanus, Diphtheria
Measles, Mumps, Rubella
None
We conduct a mandatory home safety audit and provide recommendations. Do you have any specific areas of concerns regarding falls and/or security?
Please mention the main areas where you anticipate need for support (e.g. hospital visits, preventive care, mental engagement, house staff, social connections etc. Remember that the best care is not only to take care of problems, but also to enhance quality of life.)
What should we prioritise first?
Help use technology
Communication (Mobile phone, WhatsApp)
Entertainment (Youtube/Netflix)
Useful services (Uber/Ola, Online bill payments/Banking/Shopping)
Encourage outdoor activities - Coffee, temples, exhibitions, events
Encourage indoor activities - reading / games
Medical support required
Organise medical help at home
House maintenance/Errands
Emergency Hospital Name (If not aware, fill NA)
*
Emergency Hospital Contact Number
Emergency Hospital address
Do parents have househelp at home
Yes
No
Do you want to add another family member to care team (your siblings or spouse):
Yes
No
First Name
*
Middle Name
Last Name
Address
Mobile Number
*
Email ID
*
Do you want to add another family member to care team (your siblings or spouse):
Yes
No
First Name
*
Middle Name
Last Name
Address
Mobile Number
*
Email ID
*
Do you want to add another family member to care team (your siblings or spouse):
Yes
No
First Name
*
Middle Name
Last Name
Address
Mobile Number
*
Email ID
*
Declaration:
*
I hereby agree to the
Privacy Policy
and
Terms & Conditions.
*
I further declare that, to the best of our ability, we will be providing a safe working environment for your Care Counsellor and service providers. Mental disorders, If any, have been mentioned in the form above and the residents do not have any communicable disease. We would be treating the care counsellor and service staff with courtesy and respect – without discrimination or harassment. We shall be available for visits and will inform the Care Counsellor, if we will not be available for a scheduled visit.
*
Refer / Enquire
Name*
Mobile Number*
Email*
College/Institution*
Graduation Year*
What would you like to do?*
—Please choose an option—
Ask a query
Share experience
Talk to a reference
Add Description*
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