How did you hear about Canary Home Visits? *

Family or friend

Doctor or other healthcare or homecare professional

Community event or senior center

Online search or social media

Advertisement in the mail

Local newspaper or magazine

Other

Please Include Here

Are you inquiring about home visits for yourself or someone else? *

Myself

Someone else

If Someone else, for whom are you inquiring?

Please Explain

Are they aware that you’re inquiring about home visits for them? Please select one.

Yes

No

Not yet

I’m not sure

In which of the following is the care recipient living today (please select one):

Please provide the care recipients address below: *

City

State

Country

Postal code

What other in-home care is the care recipient receiving currently? Please check all that apply

No other in-home care providers currently

Homecare agency providing in-home aides

Home health agency providing skilled services (ex. RNs, OTs/PTs, Infusion)

Hospice care providing hospice services

Medical equipment company delivery & servicing medical equipment

Other

If the care recipient is receiving care from a Homecare agency, are you looking to supplement this care with Canary Home Visits or to replace this care with Canary Home Visits?

Supplement

Replace

I’m not sure

If the care recipient is receiving care from a Homecare agency, are you looking to supplement this care with Canary Home Visits or to replace this care with Canary Home Visits?

How many days per week does the Homecare agency noted above provide in-home care:

Are you aware that Canary Home Visits does NOT provide hands-on care, transportation, medication administration, medical care, or medical equipment?

Yes

No

I’m not clear on the service that Canary Home Visits provides

At this point, which Membership Option are you most considering from Canary Home Visits?

Daily Vitality – 7 visits per week ($399 per week or $57 per visit)

Frequent Flourish – 5 visits per week ($299 per week or $60 per visit)

Regular Rejuvenation – 3 visits per week ($199 per week or $66 per visit)

Weekly Wellness – 1 visit per week ($99 per week)

I’m not sure yet

Message

Please include questions you may have below so our Care Coordinator can be best prepared to address them when they contact you: Thank you for contacting Canary Home Visits. Your inquiry has been received and routed to our Care Coordinator. Our team will be in touch with you within 24 hours.