In-Home Personal Care Consent Form
Client Name:
Date of Birth:
Address:
Phone Number:
Care Services
Type of Services to be Provided:
Scheduled Dates/Times:
Care Provider's Name:
Consent & Authorization
I hereby consent to receive in-home personal care services as described above. I acknowledge that I have been informed about the nature, risks, and potential benefits of the services and that all my questions regarding the care have been answered.
I have read and understand this consent form.
I authorize the care provider to perform the services listed above.
Client/Representative Signature:
Date:
Care Provider Signature:
Date: