Medivac Caregiver Service Form Caregiver Service Form 12345 PART I: Client InformationOrder Number (Hidden)This field is hidden when viewing the formOrder Number(Required)Client Name(Required)ID Number [ As per NRIC or Passport Number ](Required)Address [ As per NRIC ](Required) Street Name Unit Number Postal Code Email(Required) Mobile Number(Required) PART II: Verify Your IdentityVerify Your Identity(Required) Identity Document Select Your Document Type(Required) Passport ID Card Singpass Upload of Client ID [ Front ](Required) Drop files here or Select files Max. file size: 10 MB, Max. files: 1. Upload of Client ID [ Back ] Drop files here or Select files Max. file size: 10 MB, Max. files: 1. PART II: Product InformationThe Standard Waiting Time : 1 - 3 hoursThis field is hidden when viewing the formCare Giver Service(Required) Choice number 1 does not have an image Care Giver Service No of Days Required(Required)No of Hours per Day(Required)Care Giver Service(Required) Price: $ 0.00 Care Giver Start Date(Required) DD slash MM slash YYYY PART III: Your Total BillCare Giver Service(Required)Your Estimate BillYour Estimate Bill(Required) PART IV: Financial Counselling for Caregiver Service To: MEDIVAC EMERGENCY AMBULANCE SERVICE P/L 202320939D FINANCIAL COUNSELLING FOR CARE GIVER SERVICE This is to confirm that I: I have been informed that: The total package for the caregiver fee is : S. Caregiver Start Date : No of Hours per day : No of Days required : The caregivers engaged by me are not healthcare workers but are trained to : Accompany patients for medical appointments Check basic vital signs and management of chronic illness Provide clinical skills like tube feeding , oral suctioning , catheter care , tracheostomy care , management of ventilator emergencies and administration of subcutaneous (SC) injections. All medical disposables and equipment will be provided by me. I agree to cover all incidental expenses and payments that may arise on our behalf. I undertake to pay all your fees and fully indemnify you for any costs, expenses, or disbursements incurred while providing care for the patient. In the event of any payment default, I agree to be fully responsible for and guarantee the settlement of all outstanding payments owed to Medivac Emergency Ambulance Service Pty Ltd. Additionally, I understand that I will be responsible for covering all legal costs and expenses on a full indemnity basis that arise from or are related to Medivac Emergency Ambulance Service Pte Ltd's efforts to recover or attempt to recover any amounts owed by me. I also agree that there will be no cancellations, prorations, or deductions of fees for any unused hours for any reason. This policy is in place to account for the opportunity cost incurred by the caregivers who have reserved their time to care for the patient. Payment of service shall be made immediately upon delivery of service through Bank transfer (i.e. Paynow). This Agreement shall be deemed to be made under and governed by the laws of the Republic of Singapore in all respects, including matters of construction, validity, and performance. *Note : The parties agree that to the extent they sign electronically, their electronic signature is the legally binding equivalent to their handwritten signature.Signed and Agreed By :I Agree I Agree Full Name [As per ID](Required)Signature(Required)
