Birth Date
Reason for service request?
Any pets? YesNo
If yes, how many?
Special diet requirements? YesNo
Food intolerances or dislikes?
Start Date
Meal Selection Hot MealSoup Sandwich ComboSandwichFrozen Meal
Are you a smoker? YesNo
Do you live alone? YesNo
Anyone else home when meals delivered? YesNo
Can you answer the door to receive meal? YesNo
Can you hear telephone/bell/buzzer when volunteer arrives? YesNo
Food allergies YesNo
Days required? MonTueWedThuFri
Invoice sent to yourself? YesNo
If no, to whom?
Emergency Contact 1
Emergency Contact 2
Other Service Providers
Nursing YesNo
Have you been assessed by Ontario Health? YesNo
Do you have connect care? YesNo
Homemaking YesNo
Note: There is a minimum trial period of 10 hot meals and clients will be charged for 10 days even if services is cancelled earlier. Clients are invoiced at the end of the month. Invoices are sent by email or hand delivered by volunteer.
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