New Family Intake Form with LinkRx

Welcome to LinkRx

We understand choosing care and companionship for your loved one is a deeply personal decision. This intake form helps us learn about your family's needs, preferences, and any special requirements so we can match the right companion or care service.

Need immediate assistance?

Call to Book Now

+1 (604) 338-3098

Family Information

First name *

Last name *

Family contact person email *

Contact Phone Number *

Phone

Services

Select one

Companionship

Care

Senior / Resident

Name of Senior *

Age (optional)

Name of the Facility *

Resident Room number *

What are the residents' likes (hobbies) and dislikes? What did they do in their earlier days? *

Any particular item we should watch out for e.g allergies *

Tell us in brief what medical items we should know. Please add mobility, use of glasses or hearing aids if applicable *

Preferences & Schedule

Companion preference *

Preferred languages *

Preferred start date *

Frequency of service * (select one or more days)

Preferred Time of Service *

Payer information

Is the contact person the payer? *