• Service Admission Form

    Service Admission Form

  • 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 for services to start a method of payment will need to be collected.

  • Client Information

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  • Financial Profile

    Fill out any financial benefits you may currently have.

  • I agree to receive email notifications regarding, but not limited to, appointment reminders, scheduling changes, newsletter, education / injury prevention materials and information about services offered by Ohana Care. I understand that I may opt out at any time by unsubscribing or by informing Ohana Care in writing that I no longer wish to receive email

  • I hereby consent and authorize an employee or representative of Ohana Care to perform nursing foot care services. I also 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 that you provide us herein.

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  • Billing Information

    Please enter the information for the individual who is responsible for payment of services.

  • Rates and Method of Payment

  • Alberta Area:

    • Client acknowledges a rate of $64.99 per visit for foot care services, or $79.99 to add hand care service
    • Client acknowledges a rate of $39.99 per hour for certified health care aide services for a minimum of 4-hours
    • Client acknowledges that they will be invoiced for all expenses incurred by the caregiver during a scheduled visit. Review of receipt and spending available upon request. Inclusive of parking on street or within paid parking lots
    • Client acknowledges that travel outside of city limits will equate to $0.50 KM invoiceable to the client and/or travel with the client within city limits will be reimbursable at the same rate
    • Client acknowledges that a cancellation fee is applied if an employee arrives for a scheduled shift or if less than 24-hours of notice is provided prior to the scheduled start time of the visit
    • These rates are subject to change by Ohana Care upon thirty (30) days written notice

  • Vancouver Area:

    • Client acknowledges a rate of $79.99 per visit for foot care services
    • Client acknowledges a rate of $44.99 per hour for certified health care aide services for a minimum of 4-hours
    • Client acknowledges that they will be invoiced for all expenses incurred by the caregiver during a scheduled visit. Review of receipt and spending available upon request. Inclusive of parking on street or within paid parking lots
    • Client acknowledges that travel outside of city limits will equate to $0.50 KM invoiceable to the client and/or travel with the client within city limits will be reimbursable at the same rate
    • Client acknowledges that a cancellation fee is applied if an employee arrives for a scheduled shift or if less than 24-hours of notice is provided prior to the scheduled start time of the visit
    • These rates are subject to change by Ohana Care upon thirty (30) days written notice

  • Payment Terms

    Home Care services are billed monthly.

    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:

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  • Service Agreement & Consent

  • 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.

  • Authorization

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  • Optional Free Feature - Family Portal

  • Stay engaged in you or your loved ones care through our secure, always available Family Portal

    Ohana Care’s family portal provides real-time access to your care information from anywhere, on any device.

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    • 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

  • Family Portal Accounts to Create

    For more than two accounts, please contact us. Account login information will be sent to you once our Administrative team has processed the requests.

  • Authorization to view Data

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  • Should be Empty: