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Home
About
Services

24 Hours Emergency Services

Care Companions

Elder Care

Secure Your Home

Non Medical Urgencies

Medical Equipment Provider

Alzheimer’s / Dementia Care

Clinical Support

End Of Life Rites
Our Plans
Sahochar Plan
Registration Form
Contact Us

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Registration Form

KNOWING THE MEMBERS: MEMBER INFORMATION

Details of 1st Member:

Mr Mrs Ms Dr

First Name:

Last Name:

Gender:

Male Female

Blood Group:

Date of Birth:

Email:

Mobile:

Phone:

Details of 2nd Member:

Mr Mrs Ms Dr

First Name:

Last Name:

Gender:

Male Female

Blood Group:

Date of Birth:

Email:

Mobile:

Phone:

Preferred mode of communication:

Phone:

Email:

Preferred Language:

Bengali Hindi English

Address:

Floor:

Pin Code:

Landmark:

Lift Available:

Yes No

Emergency Details:

Member needs 24X7 Ambulance Facilitation Services?

Yes No

Member needs Holpitalization Help Services?

Yes No

Member needs SOS Phone?

Yes No

Local Emergency Contact ( Relative or Responsible Friend / Neighbour )

Name:

Address:

Mobile:

Relationship with Senior Citizen:

Can be contacted at night:

Yes No

Local Emergency Contact 2 ( Relative or Responsible Friend / Neighbour )

Name:

Address:

Mobile:

Relationship with Senior Citizen:

Can be contacted at night:

Yes No

Important Contact Details:

Primary Contact Person/Next of Kin:

Title

Mr Mrs Ms Dr

First Name:

Last Name:

Gender:

Male Female

Date of Birth:

Email:

Mobile:

Phone:

Address:

Primary Physician (Member 1)

Name:

Phone:

Speciality:

Hospital/Nursing Home associated with:

Primary Physician (Member 2)

Name:

Phone:

Speciality:

Hospital/Nursing Home associated with:

Preferred Hospitals for Emergency Situations:

Insurance Details:

1st Member

Company

Policy Number

Policy Details

Photocopy of Policy Provided:

Yes No

2nd Member

Company

Policy Number

Policy Details

Photocopy of Policy Provided:

Yes No

No. of Family Members in house:

General home condition for patient safety (Bathroom, Fall risk, etc)

Neighbourhood safety (eg. are the neighbours friendly, what happens for an emergency response

Type of support required (eg. adult companionship or caretaker)

Other Issues

Autumn Leaves Care Package:

Monthly Registration Fee

Annual Registration Fee

Terms And Conditions

I agree to the terms and conditions of Autumn Leaves and possess the validation and authoritative power to represent the Member or members.
I willfully allow them to take care and give assistance to the aforementioned members /dependents in order to arrange for routine or emergency medical and dental treatment required for the member. In the event that the member is injured or ill while under the care of the care giver, I hereby permit the care giver of Autumn Leaves to provide first aid for the aforesaid dependent and to take the appropriate measures owing to the situation. This includes contacting the emergency medical service and arranging for transportation to the nearest emergency medical facility.
While taking decisions related to medical assistance on my behalf for the benefit of my dependent, I direct that the caregiver attempt to contact me. However, if medical care becomes essential, I allow the caregiver to make such decisions regarding such treatment as deemed appropriate by the medical doctor, hospital or their authorized designee. In furtherance of any treatment decisions to be made by the caregiver on my behalf for the benefit of my dependent/member, I authorize the Autumn Leaves personnel to request, obtain, review and inspect any and all necessary facts bearing upon my dependent's health and relevant to any such decisions to be made respecting such treatment.
I acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on the condition of my dependent /member and that I take the responsibility for all reasonable charges in connection to the care and treatment given to my dependent / member during this tenure.

Member or Family Friend:

Date:

Membership Start Date:

Membership End Date:

Signature and Name of Autumn Leaves Personnel: