Oakville Meals on Wheels

Client Application Form




Birth Date



Reason for service request?

Any pets?

If yes, how many?

Special diet requirements?

Food intolerances or dislikes?

Start Date


Meal Selection

Are you a smoker?

Do you live alone?

Anyone else home when meals delivered?

Can you answer the door to receive meal?

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

Food allergies

Days required?

Invoice sent to yourself?

If no, to whom?

Emergency Contact 1




Emergency Contact 2




Other Service Providers

Nursing

Have you been assessed by Ontario Health?

Do you have connect care?

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