New Patient Checklist

Employee Name Filling Out This Form — First Name *

Employee Name Filling Out This Form — Last Name *

Employee Email *

Patient Intake Form Completed — Complete? *

Patient Intake Form Completed — Date Completed

Application Date on Website

Assigned LarCare Patient Number

In-Home Aide Supervisory Visit Report — Complete? *

In-Home Aide Supervisory Visit Report — Date Completed

New Patient Checklist — Complete? *

New Patient Checklist — Date Completed

Patient Type

Does the Patient Have CLTC or Different Type of Patient Number

What Is The Number

Service Plan Reviewed — Complete? *

Service Plan Reviewed — Date Completed

Personal Care Log — Complete? *

Personal Care Log — Date Completed

Right to Complain — Complete? *

Right to Complain — Date Completed

Advance Directives — Complete? *

Advance Directives — Date Completed

SC LARCARE INC Client Non Solicitation Agreement — Complete? *

SC LARCARE INC Client Non Solicitation Agreement — Date Completed

SC LarCare Inc Emergency Preparedness Plan — Complete? *

SC LarCare Inc Emergency Preparedness Plan — Date Completed