Contact Details - Details of Person(S) Requiring Assistance

CLIENT REGISTRATION FORM CONTACT DETAILS - DETAILS OF PERSON(S) REQUIRING ASSISTANCE Name:...... Address:...... Postcode:...... Telephone:......

DETAILS OF PERSON DEALING WITH THE BOOKING: (If different from above – please advise relationship with client): Name:...... Relationship with Client: ...... Address:...... Postcode:...... Telephone (Home):...... Telephone(Work):...... Email:...... Mobile:......

DETAILS OF ALTERNATIVE PERSON WE CAN CONTACT: Name:...... Relationship with Client: ……...... Address:...... Postcode:...... Telephone (Home):...... Telephone(Work)...... Email:...... Mobile:......

NEXT OF KIN: Name:...... Relationship with Client: ...... Address:...... Postcode:...... Telephone (Home):...... Telephone(Work):...... Email:...... Mobile:......

ACCOUNT TO BE SENT TO: Name:...... Relationship with Client: ...... Address:...... Postcode:...... Telephone (Home):...... Telephone(Work):...... Email:...... Mobile:......

DETAILS OF PERSON COMPLETING FORM: Name:...... Relationship with Client: ...... Address:...... Postcode:...... Telephone (Home):...... Telephone(Work):...... Email:...... Mobile:......

DATE HELP REQUIRED FROM: ...... TO:......

I agree to and will abide with the Terms of Business. I have enclosed the non refundable lifetime registration fee.

Signature:...... Date:......

If the person completing this form is different from the person for whom the help is required that person has the full authority of the person for whom the help is required; both parties accepting liability for all fees charged by the Agency.

The Care Agency is a trading name of MiHomecare Limited a company registered in England under company number 3203080 at 1 Harlequin Office Park, Fieldfare, Emersons Green, Bristol, BS16 7FN, UK. GENERAL INFORMATION

HOUSEHOLD DETAILS Type of property: ...... Number of bedrooms: ...... Method of cooking (gas, electricity, solid fuel, aga, microwave etc): ...... Central Heating: ...... Washing Machine: ...... Dishwasher: ...... Television: ...... Details of Carer’s accommodation: ...... PLEASE NOTE ALL CARERS MUST BE ALLOCATED A SEPARATE BEDROOM

Is there a cleaner (if so, how many hours per week): ...... Are there any other staff (if so, please give details): ...... What animals (if any) in the household: ...... What will be duties in respect of any pets: ...... Is a car driver required (if so, please give details of car available for use):...... Manual/Automatic...... Is adequate insurance cover in place/being arranged:...... Nearest Railway Station:...... Distance from property: ...... Will the carer be collected from the station or take a taxi: ...... Is it a non-smoking home: ...... Is a non-smoker preferred:...... DAILY ROUTINE Please give any special dietary requirements: ...... Please indicate when the main meal of the day should be provided:...... At approximately what time does the client wake and get up: ...... At approximately what time does the client retire for the night: ...... Does the client rest at regular times:...... Is assistance required at night (if so, please give details):...... Does the client have regular visitors: ...... If so, do they call at specific times: ...... Does the client go out to regular appointments/visit friends: ...... Does the client enjoy specific television programmes: ...... Does the client have any special interests or hobbies:......

The Care Agency is a trading name of MiHomecare Limited a company registered in England under company number 3203080 at 1 Harlequin Office Park, Fieldfare, Emersons Green, Bristol, BS16 7FN, UK.

PERSONAL DETAILS (PLEASE COMPLETE FOR EACH PERSON IN THE HOME)

Name:...... Date of Birth:...... Height:...... Weight: ...... Nature of illness:...... Any loss of Speech: ...... Hearing: ...... Is/are aid(s) used: ...... Sight: ...... Is mobility restricted:...... Is a walking stick used: ...... Is a frame used: ...... Is a stairlift used:...... Is a wheelchair used:...... indoors:...... outside:...... Is a hoist used (please give details: ...... Is assistance needed with: feeding:...... dressing: ...... washing: ...... bath:...... shower:...... Is toileting help required (if so how much):...... Is there a commode: ...... Degree of incontinence (if applicable): ...... Are pads available: ...... Are other aids available:...... In case of senility, what degree: ...... Does the client need prompting to take medication: ...... Does the District Nurse call: ...... If so, how often: ...... What for: ......

DOCTOR’S DETAILS Name:...... Address: ...... Telephone number: ......

Please give any other useful information that you feel may be relevant:: ......

The Care Agency is a trading name of MiHomecare Limited a company registered in England under company number 3203080 at 1 Harlequin Office Park, Fieldfare, Emersons Green, Bristol, BS16 7FN, UK. TERMS OF BUSINESS

1. Carer’s Charges

a. Salaries including provision of full board and lodging must be arranged between the Carer and the Client for the dates of care provided on the booking confirmation issued by the Agency to the Client. The Agency’s charges are sent to the Client separately and are payable in accordance with paragraph 3 below.

b. Salary rates are dependent on the level of care required. The exact figure will be discussed and agreed between the Client and the Carer prior to the Carer commencing the assignment. Carers’ salaries will be reviewed annually, however salaries may also be reviewed to reflect changing needs as required.

2. Bank Holidays and Additional Charges

a. All Carers undertaking work over Statutory Bank Holidays receive enhanced pay for these days i.e. New Year’s Day, Good Friday, Easter Monday, May Day, Spring and Autumn Bank Holiday Mondays, Christmas Day and Boxing Day. This is twice the normal daily rate and should be agreed between the Client and Carer.

b. Carers are classed as self-employed for National Insurance and Income Tax purposes and will be responsible for their own contributions.

c. Travelling arrangements and expenses for the Client’s excursions and domestic requirements should be agreed between the Client and the Carer in advance. The Client is liable for the Carer’s travelling expenses directly to the Carer.

d. If a Carer is allowed or required to drive the Client’s car he or she will do so entirely at the Client’s risk. Clients should ensure before allowing the Carer to drive their car, that there is in place a valid insurance policy which permits “Other Drivers”. It is also advisable to check that the Carer has a valid driver’s licence. The Agency cannot be held liable for any damage caused to vehicles, whether owned by the Client or Carer.

e. Carers should only use the Client’s telephone and/or Wifi by prior agreement with the Client. The Agency will not be responsible for any costs incurred by the Carer’s use of the Client’s telephone line.

3. The Agency’s role and fees

a. Every effort is made by the Agency to ensure reasonable standards of skills, integrity and reliability from Carers and to match the Carer to each Client’s requirements. No liability is accepted for his or her fitness for the post involved. At no time does the Agency act as employer of the staff it introduces. References, DBS and right to work documents are obtained by the Agency for all Carers before they are sent to work for the Client.

b. The Client will be charged:

(b.i) a non-refundable lifetime registration fee of £75.00 ; and (b.ii) an Agency fee of £16.07 per day for each day of care (including travel time) (“Agency Fees”) provided by the Carer in accordance with the booking confirmation issued by the Agency together with VAT. Agency Fees are invoiced to the Client after the Carer has taken up a position at the end of the same month. All invoices are payable within 14 days of receipt of the invoice. Cheques should be made payable to MiHomecare Limited.

c. If a placement is cancelled once the Booking Confirmation has been confirmed in writing there will be a cancellation fee of £112.49 (this fee is subject to VAT at the current rate) payable by the Client to the Agency. The Client is also liable for a week’s salary payable to the Carer unless we are able to offer an alternative placement for the same dates.

d. We are more than happy for Carers to return to a particular Client following the end of a placing but Clients must arrange additional placements through the Agency and not directly with the Carer. If the Client engages a Carer other than through the Agency, whether for financial consideration or not, the Client will pay to the Agency a one-off fee of £2249.52 (this fee is subject to VAT at the current rate) acknowledging the initial introduction of the Carer by the Agency. Furthermore, should a Client directly or indirectly introduce a Carer previously introduced to them by the Agency to a third party, with a view to that Carer working for that third party, then the Agency will charge the original client the one- off fee of £2249.52 (this fee is subject to VAT at the current rate).

The Care Agency is a trading name of MiHomecare Limited a company registered in England under company number 3203080 at 1 Harlequin Office Park, Fieldfare, Emersons Green, Bristol, BS16 7FN, UK. e. Should a Carer be asked to leave before the final date stated on the Booking Confirmation, once they have commenced the assignment, there will be no amendment to the Agency Fee. The Client is also liable to pay the Carer for the entire assignment stated on the Booking Confirmation unless we are able to offer the Carer alternative placements- in this case the Client is liable for their salary from the original starting date until the date the alternative assignment commences (In both situations every effort will be made to find an acceptable alternative post but this cannot always be guaranteed).

f. If a Carer leaves an assignment for any reason before the agreed completion date, the Agency’s fee will be amended on a pro-rata basis and the Carer’s salary will be payable only for the time worked.

4. Personal Information

a. The Agency will use the information Clients provide to the Agency to: (i) provide the Agency services; (ii) process payment for the Agency services; and (iii) conduct our own internal research with a view to improving the Agency services or developing new services.

b. The Agency will only share Clients’ information with the Carers who will provide them with the care services.

c. The Agency will treat the information which Clients provide to the Agency as confidential. Where Clients’ family, friends, representatives or carers provide the Agency with information about themselves, the Agency will also treat this information as confidential.

d. The Agency will only provide third parties not listed above with Clients’ information if Clients provide the Agency with explicit consent to do so.

e. In order to provide the Agency services the Agency will need certain information from the Client. If the Agency asks for information and the Client does not provide such information, or the information which the Client does provide is incomplete or incorrect, it is possible that the Agency may not be able to provide the Agency services.

f. If the Client does not provide the information which the Agency has asked for, or that information is incomplete or inaccurate, the Agency will not be liable to the Client for any delay or failure to perform the Agency services which occurs as a result.

The Care Agency is a trading name of MiHomecare Limited a company registered in England under company number 3203080 at 1 Harlequin Office Park, Fieldfare, Emersons Green, Bristol, BS16 7FN, UK.