HIPAA Privacy

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HIPAA Privacy Notice
Emergency Assistance
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Scope of Practice AZNHA
Speaking

Serving Tucson Area

jantaplin@yahoo.com

520-415-6363

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Reach out to us

Get more information

My Name:

The person needing assistance is

My Mom

My Dad

My Grandfather

My Grandmother

My Aunt

My Uncle

My Neighbor

My Friend/ Acquaintance

Other

What tasks are becoming more difficult?

Getting Dressed

Walking Safely

Shopping/ Errands

Cooking

Cleaning House

Remembering to take Medication

Organizing my Paperwork

Driving Safely

Making the Bed

Getting in the Shower Safely

My kids think I need help, I think I am doing just fine.

Keeping track of doctor appointments

Remembering what the doctor(s) told me at the appointment(s)

Phone number

Email (if you have one)

How soon might you need care?

2-3 days from now

5-7 days from now

8-14 days from now

Next Month

When I return in the fall

Gathering information at this time

Other important information about yourself and the assistance you are seeking.

Confirm that your phone and email are correct

Yes

Got it corrected!

Major cross streets or address where the person needing help lives

How did you hear about us?

Senior Fair

Read Article in Oro Valley Style Mag.

Someone gave me your name/ card

Google Search

Nextdoor

Pima Counsel on Aging Resource Guide

Other

Heard Dr. Jan Speak at Senior Academy

What are you most interested in/ or most need of? Check all that apply

Regular help in my home.

Someone to contact in Emergencies.

A Guide to help navigate all the challenges.

First Name of person needing care

Thank you for contacting us.

If you do not hear from us within 2-4 hours, PLEASE SEND A TEXT OR CALL 520-415-6363 in case there was a glitch in the system.

Thanks Much!

Jan and Bob

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Please call or text the office at 520-415-6363

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