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HealthCruit

Recipient Onboarding

This form should ONLY pertain the care recipients information. If you are filling out this form on behalf of the care recipient please check the box at the end of this form.

Date of Birth
Month
Day
Year
How many people need care?
Gender of recipient
Preferred caregiver gender
Do you have pets?
How soon do you need care?
How long do you want to continue care?
Do you have a spare room with a bed and dresser?
Do you use medical devices?
Do you need memory care?
How many times does the recipient get up at night?
Is the recipient a flight risk
Preferred Language
Religion
Preferred Date and time
Month
Day
Year
Time
HoursMinutes
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