Care Information Request Contact InfoName(Required) First Last Email(Required) Daytime Phone(Required)How should we contact you?(Required) Email Phone Care InformationClient Name (if different):(Required) First Last I am looking for care for:(Required)MeMy SpouseMy ParentA Family MemberA FriendOtherCare will be provided in:(Required)BurlingtonHalton HillsMiltonOakvilleWhat type of care are you looking for?(Required) I’m not sure and I don’t know where to start Personal Support Nursing Companionship Private Respite Care Foot Care Grocery Shopping Transportation to Appointments Meal Preparation Housekeeping Social Support Fall Prevention Hospice Care Dementia Care – Adult Day Program (Clubs) Dementia Care – Overnight Respite Bereavement Support Languages SpokenAnything else you'd like us to know?Permission to Submit(Required) I agree Acclaim Health is committed to individual privacy and has taken reasonable precautions to ensure the security of the information you are submitting through this online form. By clicking “I agree” you are acknowledging and accepting the potential risks inherent in submitting personal information and/or personal health information online. Please contact us by telephone at 905-827-8800 if you do not wish to submit this information online and we will be happy to assist you.CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
