For Families – 24hseniorenpflege.de

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For Families

/ For Families

Contact form

A notice! After completing the form, it will be sent to our office and subject to manual verification.

Client

Surname:

First name:

Street, No:

ZIP / City:

Phone:

E-mail:

Fax:

The person/persons to be cared for

IndividualCouple

Surname:

Street, No:

ZIP / City:

Phone:

Fax:

Birthday:

Place of birth:

Nationality:

Knowledge of other languages:

Who is the invoice recipient

The following illnesses/disabilities/restrictions are present

Health impairments:
mentally and physically fitmentally fit and physically illmentally ill and physically fitmentally and physically ill

Additionally please indicate:

can walk alone:
yesno

can run with help:
yesno

Wheelchair:
yesno

Bedridden:
yesno

can go to the toilet independently:
yesno

Partial incontinence:
yesno

Total incontinence:
yesno

Care level:
123norequested

Height:

Weight:

KIs there an outpatient nursing service? If so, how often and what tasks are performed?

The following activities are necessary. Please provide a precise description and, if possible, a rough daily routine

Working hours/duration

Is night duty necessary, and if so, to what extent?

Time off in lieu (e.g. hours/day)

When should the assignment take place?

Estimated duration of the assignment:

Space for further details or for wishes regarding the qualification and characteristics of the strength to be conveyed and special requirements for the strength (e.g. age, strong person, non-smoker, driver's license, hobbies, love of animals, etc.)

Additionally please indicate:
FemaleMale

Knowledge of German:
Basic knowledgeAdvanced knowledge (understanding well, speaking with difficulty)Good knowledge (simple conversations are possible)Very good knowledge (conversations are possible without restrictions)

Description of the accommodation (location, size, facilities, etc.)

Are there pets in the household?

Other communications, questions or comments

I declare that I have read the regulations and accept them. I declare that I have read the privacy policy.

Contact

DE, Frankfurt am Main: (+49) 069/40592430

CH, Zürich: (+41) 43/5507656

CH, Genf: (+41) 22/5083758

Adres email: info@24hseniorenpflege.de

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