GentleCare Men's Care - Punkit-Creative (Pty) Ltd

GentleCare - Men's Care

Blank Form (#5)

First Name

Last Name

Relationship to Client

Contact / WhatsApp

First Name

Last Name

Client’s General Location in Klerksdorp (e.g., Suburb name)

Current Living Situation

What is the primary difficulty the client is experiencing? (Select all that apply)

Mobility issues

Weakness or Fatigue

Cognitive Decline

Pain

Post-surgery recovery

Lack of confidence

Does the client require assistance with any of the following? (Select all that apply)

Nail or Foot Care

Hair Washing or Trimming

Changing clothes or linen

General Grooming (shaving, dental)

Assistance with bathing/showering is required:? (Select all that apply)

Daily

3-4 times per week

1-2 times per week

Only occasional help needed

Please briefly describe any specific concerns or requirements Frans should know about.

Preferred Time for a Callback from Frans

I understand that submitting this form is a request for a **confidential consultation** and does not obligate me to book services.

I agree

Passionate about all things design.

Send us a WhatsApp on

084 440 3252

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