Registration Form : Elder Care Packages
1. Knowing the members : Member Information
Name of First member :
Select Title
Mr
Mrs
Ms
Dr
First Name:
Middle Name:
Last Name:
Sex
Male
Female
Date of Birth
E-mail
Mobile
Phone
Name of Second member :
Select Title
Mr
Mrs
Ms
Dr
First Name:
Middle Name:
Last Name:
Sex
Male
Female
Date of Birth
E-mail
Mobile
Phone
Name of Third member :
Select Title
Mr
Mrs
Ms
Dr
First Name:
Middle Name:
Last Name:
Sex
Male
Female
Date of Birth
E-mail
Mobile
Phone
Preferred mode of communication
Phone
E-mail
Phone / E-mail
Preferred Language
Bengali
Hindi
English
Address
Floor
Pin Code
Landmark
Lift Available ?
Y
N
2. Emergency Details:
Member needs 24X7 Ambulance Facilitation Services?
Y
N
Member needs Hospitalization Help Services?
Y
N
Member needs SOS phone?
Y
N
Contact#1 Kolkata based Relative or Responsible Friend/ Neighbour
Name
Address
Mobile Number
Relationship with Senior Citizen:
Can be contacted at night
Y
N
Contact#2 Kolkata based Relative or Responsible Friend/ Neighbour
Name
Address
Mobile Number
Relationship with Senior Citizen:
Can be contacted at night
Y
N
3. Important Contact Details:
Primary Contact Person/Next of Kin:
Select Title
Mr
Mrs
Ms
Dr
First Name:
Middle Name:
Last Name:
Sex
Male
Female
Date of Birth
E-mail
Address
Primary Physician: (Member 1)
Name
Phone No.
Speciality
Hospital/Nursing Home associated with
Primary Physician: (Member 2)
Name
Phone No.
Speciality
Hospital/Nursing Home associated with
Primary Physician: (Member 3)
Name
Phone No.
Speciality
Hospital/Nursing Home associated with
Preferred hospitals for emergency situations
1
2
3
4
4. Insurance Details:
1st Member
Company
Policy Number
Policy Details
Photocopy of Policy Provided
Y
N
2nd Member
Company
Policy Number
Policy Details
Photocopy of Policy Provided
Y
N
3rd Member
Company
Policy Number
Policy Details
Photocopy of Policy Provided
Y
N
5. Environmental Factors
How many people in the house?
(Age/Relationship)
General home condition for patient safety (Bathroom, Fallrisk, etc.)
Neighbourhood safety (e.g are the neighbours friendly, what happens for an emergency response
Do the members need adult companionship or caretaker, if living alone?
Other Issues
Submit