Home-Care Intake & Admission Form — Personal Touch Care Team

Please complete this form to begin services with Personal Touch Care Team, or to request an intake visit. A care coordinator will contact you to complete admission. Fields marked optional may be left blank.

Client Information Client full name Client date of birth (optional) Home address / city Nearest office

Contact Person Your name (client or authorized representative) Relationship to client (self, daughter, POA, etc.) Phone number Email (optional)

Care Needs Services of interest Preferred start date (optional) Notes for our care team (optional)

Text Message Updates

OPTIONAL I agree to receive appointment / home-visit reminders and care-coordination text messages (SMS) from Personal Touch Care Team (SMS operated by AI Revenue Forge Inc.) at the phone number provided above. Message frequency varies (typically 2–10 msgs/month). Message & data rates may apply. Reply STOP to cancel, HELP for help.

See our Privacy Policy and SMS Program Terms. No mobile information will be shared with third parties or affiliates for marketing or promotional purposes.

Consenting to text messages is not required to receive care services or to submit this form. If left unchecked, we will contact you by phone or email only.

Personal Touch Care Team Inc. · Statesville (704) 876-4277 · Charlotte (704) 523-8515 · Salisbury (704) 630-0088
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