Private Patient Request

The following form can be completed for requests of Helping Hands personnel. The following form can be used for both, an inquiry for potential care and advanced bookings. After you submit the form one of our representatives will contact you within 1-3 hours.

Patient Information

Patient Name

Patient phone Number

Location of Service

Have you used our services in the past?

Details of Patient Care (Please provide a brief description of the patient’s medical history or specific requirements)

Details of Service

Type of healthcare provider(s) requested

If other please describe

Start date

End date

Is it 24-hour coverage?
yesno

Start time of shift 1

End time of shift 1

Start time of shift 2

End time of shift 2

Start time of shift 3 (if applicable)

End time of shift 3 (if applicable)

Additional information about the requested service

Contact and Billing Information

Name of Main Contact

Home Phone Number

Cell Phone Number

Email

Bill/Invoice to care of

Billing Address

Prior to our services, a Helping Hands Nursing Services Inc. Private Patient form will be emailed/mailed to the main contact, with details of our billing and payment, as well as a confirmation of the services and payment responsibility.

Please note that all contents of this form are for OFFICE USE ONLY and will be kept strictly confidential.