Oakville Meals on Wheels

Client Application Form

Birth Date



Any pets?

Special diet requirements?

Food intolerances or dislikes?

*Start Date

Meal Selection

Is the client a smoker?

Does the client live alone?

Anyone else home when meals delivered?

Can client answer the door to receive meal?

Can client hear telephone/bell/buzzer when volunteer arrives?

Food allergies

Days required?

Invoice sent to client?

Emergency Contact 1




Emergency Contact 2




Other Service Providers

Nursing

Client assessed by Ontario Health

Client has connect care?

Client assessed by LHIN

Homemaking

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. Invoice are sent by email or hand delivered by volunteer.