Thank you for choosing Ohana Care!

To start the intake form, please select one of the services below. If you're signing up for both home care and foot care, you can select both.

This form is saveable. Simply select save for later at the bottom of each page and you will receive an email link to continue at a later date.

Once you have submitted the form, our Care Team will follow up with you about scheduling services. 

Please note: In order to submit a finished form, the method of payment section needs to be completed.

Payment Terms

Home Care services are billed bi-weekly.

Our terms are net 5 days for foot care services. If any terms requiring deviation from 5 days, arrangement will need to be made with an Account Specialist prior to appointment or at time of visit. For your convenience we offer the following payment options:

I hereby consent to Ohana Care having knowledge of my credit card information and that it is the obligation of Ohana Care to keep secure such information. Ohana Care has my approval to automatically charge the weekly invoiced amount for services rendered to the credit card I have on file. I understand that it is my responsibility to contact Ohana Care immediately and advise of any changes to the credit card information on file.

Important: Upon Ohana Care adding your credit or debit card to our payment system, you will see a $0.50 authorization charge labeled: BAM*OHANA CARE. This is how we verify that the credit or debit card has been entered correctly. This authorization charge is reversed within 2 - 5 days.

I/we authorize my/our financial institution to debit/credit my/our account on (or after) the withdrawal date (on or after the 29th of every month) of each invoice for all amount owing to Ohana Care. This authorization is valid for the account information specified above, or any other account which I/we may designate in the future in lieu of the account specified above. I/we understand that in the event that a payment is returned by the bank for any reason, that I/we will be responsible for NSF and/or $25 administration charges.

I/we may cancel this agreement at any time by providing written notice at least (15) fifteen days before the next appointment date.

Authorization for Emergency Medical Services:

• I understand that Ohana Care providers are trained to respond to medical emergency situations and will call for additional emergency medical help if needed. In the event of a medical emergency occurring during my assessment, treatment, or other services, all reasonable efforts will be extended to assist in my recovery.
• I understand that I, or my duly authorized representative, is required to declare any special instructions with respect to emergency medical intervention, such as the existence of a “Living Will” or “DNR” order prior to commencing my services with Ohana Care.

Consent to Assessment, Treatment, and Healthcare Services:

• I hereby authorize Ohana Care to provide me with an assessment and treatment or to render other healthcare services. The purposes of the assessment and treatment procedures or other health care services have been explained to me.
• I understand that the treatment plan, goals, and anticipated benefits have been discussed with me and I have been given the chance to ask any questions I may have about my treatment.
• I recognize and agree that I have the right to refuse treatment or terminate services at any time by notifying me of my termination and the reason. I acknowledge receipt of the Client’s Bill of Rights.

Consent for Photographic Image:

• I hereby consent and authorize an employee or representative of Ohana Care to take a photographic image of my likeness, to be stored in both electronic and physical files for the sole purpose of identity crosscheck at the time services are rendered. We will not share, rent, nor sell the information you provide us herein.

Scheduling of Staff:

• I understand that the services provided by Ohana care will be scheduled directly through Ohana Care offices and that I nor my representatives will schedule through caregiver.
• I understand that Ohana Care caregivers are directed not to schedule care directly with myself or appropriate family members. All modifications to scheduling will be coordinated directly through Ohana Care offices.

Consent to the Collection, Use, and Disclosure of Personal or Personal Health Information:

• I understand that to provide me with services, Ohana Care will collect personal information about me (for example, name, telephone number, address and personal health number) only to the extent necessary for the services Ohana Care provides.
• I understand this information may be shared with a Health Information Custodian.
• I understand that I may withdraw my consent in whole or in part at any time by notifying my Ohana Care service provider and that my withdrawal of consent is not retroactive to information that is already collected, used or disclosed by Ohana Care.
• I have received information about Ohana Care’s Privacy Policy and I understand how Ohana Care’s Privacy Policy applies to me.
• I consent to Ohana Care collecting, using and disclosing personal or personal health information about me as set out above and in accordance with Ohana Care’s Privacy Policy.

• View upcoming and previously scheduled visits
• View all care plan tasks completed
• Review charting and progress notes
• View any vitals being monitored
• Information on your care team
• View and download your invoices
• Request new services

To learn more visit ohanacare.ca/family-portal