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 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)
Type of healthcare provider(s) requested
Critical Care NurseRNRPNPSWOther
If other please describe
Is it 24-hour coverage?
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
Name of Main Contact
Home Phone Number
Cell Phone Number
Bill/Invoice to care of
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.