178 Columbia St, Chester, SC 29706
803-209-8667
info@larcareservices.com
LAR
CARE
SERVICES
Home
Healthcare
About Us
Blog
Products
Forms
Portal
SamariCare
Contact Us
Client / Patient Personal Care Agreement
Patient First Name *
Patient Last Name *
Patient or Point of Contact Email Address *
Start Date for The First Payment *
Agency Name *
-Select-
LarCare Inc. South Carolina
LarCare Inc. DBA SamariCare
LarCare Inc. Virginia
LarCare Inc. USVI Saint Thomas
Other
Invoice Payment Type *
-Select-
Weekly
Bi-Weekly
Monthly
Other
How Many Days in Advance to Terminate the Agreement *
State of Law *
-Select-
South Carolina
St. Thomas, USVI
Virginia
Pay Rate (e.g. 15.00) *
Non-Compete / Custom Care Agreement Additional Terms *
Emergency Care Plan and Expectations *
Date-Time
Signature — type your full legal name to sign *
I have read and agree to this Personal Care Agreement *
Submit