Serving Hamilton, Butler, Clermont & Warren Counties

Consent to Services

Consent

Authorize BridgeCare to provide home care and/or transportation services. All fields marked * are required.

(513) 587-4923 [email protected]

Back to Client Portal

1Client Information

Full Name*

Date of Birth*

Street Address

City

State

ZIP Code

Phone Number*

Email Address

2Services Requested

Primary Service Needed

Preferred Start Date

I consent to receive the following services: *

Home Care Services (personal care, companion care, respite, meal prep, housekeeping, medication reminders)Non-Emergency Medical Transportation ServicesPhotography / Documentation for care records (optional)

3Emergency Contact

Emergency Contact Name*

Relationship*

Emergency Contact Phone*

4Guardian / Legal Representative (if applicable)

Complete this section only if signing on behalf of the client.

Guardian / Representative Name

Relationship to Client

5Electronic Signature

By typing your full name below, you consent to receive BridgeCare services as selected above and confirm that all information provided is accurate.

Electronic Signature (Type Full Name)*

Date*

Your submission will be sent securely to our team at [email protected]. A completed PDF copy will be available for download after submission.