Consultation

Your Information
Name*
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Phone*
Phone Type*
- Cellular
- Home
- Work
Email*
Mobile Consent*
I agree to Mobile Consent.
We often use SMS Text Messages to communicate reminders and information for those interested in receiving consultations. Do Consent to receiving these messages. You can opt-out at anytime. For more information please see our Privacy Policy.
https://www.lkhscorp.com/about/privacy/
Email Consent*
I agree to Email Consent.
We often use Emails via our email lists to communicate reminders and information about Loving Kindness for those interested in receiving consultations. Do Consent to receiving these emails. You can opt-out at anytime. For more information please see our Privacy Policy.
https://www.lkhscorp.com/about/privacy/
Are you filing this out for...*
- My Self
- Family / Friend
- My Patient
Name of the potential client
First Last

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Services
This section is intended to help us understand what level of service you may need.
Bathing
Not Needed Once Daily 2 to 3 times a day Once Weekly 2 to 3 times a week
Hair Care
Not Needed Once Daily 2 to 3 times a day Once Weekly 2 to 3 times a week
Dressing
Not Needed Once Daily 2 to 3 times a day Once Weekly 2 to 3 times a week
Lotion / Ointment
Not Needed Once Daily 2 to 3 times a day Once Weekly 2 to 3 times a week
Meal Preparation
Not Needed Once Daily 2 to 3 times a day Once Weekly 2 to 3 times a week
Eating / Drinking
Not Needed Once Daily 2 to 3 times a day Once Weekly 2 to 3 times a week

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Services
This section is intended to help us understand what level of service you may need.
Catheter Care
Not Needed Once Daily 2 to 3 times a day Once Weekly 2 to 3 times a week
Oxygen Therapy
Not Needed Once Daily 2 to 3 times a day Once Weekly 2 to 3 times a week
Wound Care
Not Needed Once Daily 2 to 3 times a day Once Weekly 2 to 3 times a week
Medication Management
Not Needed Once Daily 2 to 3 times a day Once Weekly 2 to 3 times a week
Diabetes Monitoring, Testing, Teaching
Not Needed Once Daily 2 to 3 times a day Once Weekly 2 to 3 times a week

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Services
This section is intended to help us understand what level of service you may need.
IV Therapy
Not Needed Once Daily 2 to 3 times a day Once Weekly 2 to 3 times a week
Ventelator Care
Not Needed Once Daily 2 to 3 times a day Once Weekly 2 to 3 times a week
Physical Therapy Visits
Not Needed Once Daily 2 to 3 times a day Once Weekly 2 to 3 times a week
Occupational Therapy Visits
Not Needed Once Daily 2 to 3 times a day Once Weekly 2 to 3 times a week

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Your Information