By checking this box, I confirm that:
- I am the client or an authorized decision-maker acting on behalf of the client.
- I authorize Vimsa Home Care Services to provide non-medical support services, including transportation and in-person accompaniment to and from medical appointments.
- I understand that Vimsa Home Care Services provides non-clinical assistance only, and caregivers do not diagnose, interpret medical information, provide medical advice, or make clinical decisions.
- I acknowledge that caregivers may document observations and information shared during appointments strictly for reporting purposes, without interpretation.
- I understand that while reasonable care will be provided, Vimsa Home Care Services cannot guarantee specific medical outcomes or results.
- I consent to the sharing of relevant non-medical information between Vimsa Home Care Services and the client and/or designated family contact for care coordination and reporting purposes.
- I understand that a post-visit report will typically be provided within a reasonable timeframe (e.g., within 4 hours after the visit).
- I agree to provide accurate and complete information necessary for safe and appropriate service delivery.
- I acknowledge that transportation services are provided with due care; however, Vimsa Home Care Services is not liable for delays or events beyond its control (e.g., traffic, weather, or facility delays).
- I understand that final service arrangements, including duration and cost, will be confirmed after review of this request.
- I agree to be contacted by Vimsa Home Care Services to confirm details, finalize arrangements, and discuss pricing.
I further acknowledge and consent that:
- Vimsa Home Care Services collects personal information (e.g., name, contact details, and care needs) solely for coordinating, delivering, and improving services.
- Any health-related information provided will be used strictly to ensure safe, appropriate, and personalized care, and will be handled with confidentiality.
- My information will not be sold or shared with third parties, except where necessary to deliver services, comply with legal obligations, or with my consent.
- Information may be shared internally with authorized staff and caregivers on a need-to-know basis only.
- Reasonable administrative and security safeguards are in place to protect personal information from unauthorized access, disclosure, or misuse.
- Communication may occur via phone, email, or other provided contact methods for scheduling, coordination, and follow-up.
- I may request access to, correction of, or deletion of my personal information, subject to applicable legal and operational requirements.
- By submitting this form, I consent to being contacted regarding this service request.
☐ I consent to receive Medical Accompaniment and Transportation Services from Vimsa Home Care Services and confirm that I have read, understood, and agree to the terms above, including the collection, use, and disclosure of my personal information as described.
By submitting this form, I confirm that the information provided is accurate to the best of my knowledge.