Onze diensten

First name

Last name

Phone

Residence Address Information

Multi-line address

Land/regio

Adres

Adres - 2e regel

Woonplaats

Postcode

Are you a returning client?*

Yes

House Sitting Care Schedule

How many days of care service do you need?*

FOR 3 OR MORE DAYS WRITE THEM DOWN IN THE BOX BELOW

Are there any additional days (more than 2) of house care needed? If so, please specify dates and times.*

Care Information

What is the relation to the person requiring care?

Number of people requiring care

Their Name/Gender

Their Age

Do you wish to have them taken outside of the residence?*

Yes

Do they have any allergies or health conditions?

Yes

Please specify any special needs/requirements for the person requiring care:

Personalize Your Experience

Yes, subscribe me to your newsletter.

Your Birthday

Month

Day

We'll use this to send exclusive birthday promos and discounts & a special card just for you!

Billing Authorization

I hereby authorize Family Care Options by filling out and signing this credit card authorization form to charge the credit card provided for any and all services rendered and/or ordered by Family Care Options, Inc. The credit card provided will be charged in such a manner as if I were paying in person and signing a transaction slip. I understand there will be a 4% service fee for all phone and internet credit card orders.

Home Care Bundle: $269.00 fee for Adult Care & House Sitter

Surcharge Policy: A $50.00 surcharge fee applies before 8:00 AM and/or after 9:00PM.

Cancellation Policy:

Cancellations received less than 48 hours before the scheduled start time, the client will be responsible and billed for the entire schedule of services confirmed. All hourly rates and transportation fees will be charged to the credit card provided. 

Cancellations received more than 48 hours in advance will receive a refund.

Method of Payment:

All major credit cards accepted and due upon confirming the care.

Signature

Tekenmodus geselecteerd. Voor tekenen heb je een muis of touchpad nodig. Selecteer Typen of Uploaden voor toegankelijkheid van het toetsenbord.

By checking this box, I authorize my electronic signature

By signing above, I agree and understand the Family Care Options policy, terms, rates, billing, and cancellation.

Cardholder Name

Card Number

Expiration Date (mm/yy)

CVV/Security Code

Billing Zip Code

Promo Code

Billing Phone