New Enrollee (Enrollment Form)

Enrollment Form (Revised)

Kindly fill this form, sign and return with any attachments to LINKCO via email(admin@linkcohealth.com)
PERSONAL DETAILS
Who will be receiving the service?

SelfSomeone else
Title
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date*

MonthDayYear
Contact Details Person Completing Form or Responsible Party

Request copy of POA to admin@linkcohealth.com
Name*

First NameLast Name
Home Telephone*
Mobile
Do you have a valid email address?*

YesNo
Email*
example@example.com
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Living Situation (E.g. Do you live alone, or with friends, etc.)*
Where do you live?

Private HomeGated CommunityLong Term Care Facility or Apartment Building
Name of Facility/Apartment Building
Contact Details of Care Receiver
Date of Birth *
Name*

First NameLast Name
Home Telephone*
Mobile
Do you have a valid email address?*

YesNo
Email*
example@example.com
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Living Situation (E.g. Do you live alone, or with friends, etc.)*
Where do you live?

Private HomeGated CommunityLong Term Care Facility or Apartment Building
Name of Facility/Apartment Building
Identify Preferred Method of Contact*

PhoneEmailText
(Please note that we do not send correspondence via postal mail. All invoices, statements, receipts and miscellaneous information about your account and enrollment status is communicated digitally to the email address you have on file with us.)
Email*

By completing this form and clicking submit, you agree to receive occasional emails from LinkCo with updates on services, scheduled appointments, special offers, and promotions. You can unsubscribe at any time by clicking the 'unsubscribe' link at the bottom of our emails
SMS*

By enrolling and submitting this form, you agree to receive text messages from LinkCo related to services, scheduled appointments, special offers and promotions. Message & data rates may apply. Message frequency varies.
How did hear about us?*

Healthcare ProviderFamily or FriendSocial MediaGoogle SearchOther
Name of Provider
Social Media

FacebookLinkedInInstagramTwitterYou Tube
EMERGENCY CONTACTS (KINDLY PROVIDE AT LEAST 2)

	Name	Relationship	Phone
Emergency Contact 1
Emergency Contact 2
Emergency Contact 3

HEALTH DETAILS
Do you use any medical devices or equipment?*

YesNo
Please select

Collapsible wheelchairRollatorWalkerCaneOxygen TankOther
Do you have any health challenge or medical history you think we should be aware of?

YesNo
Kindly write details below
Other Details/Comments
Please read the service terms and conditions below:
Terms and Conditions*

PIRATING CLAUSE: Pirating practices or hiring the caregiver directly and secretly, inside this agreement is strictly prohibited. In the event that the undersigned, family, or anyone directly in relation to the client, secretly hires the agency’s caregiver in the absence of any written notice whatsoever, the action will be considered a breach of contract. A fee of $10,000 will be due based upon the financial losses to business and opportunities caused by the violation. A direct violation of this clause will be considered a breach of contract and will be given to our legal counsel for the due legal process of attention and collection.DIRECT HIRING CLAUSE: In the event that the undersigned desires to hire the agency caregiver directly within the said written agreement, the undersigned is required to give a written 7 days notice of the request addressed to the agency and agrees to the pay the referral fee equivalent to two (2) months pay or two (2) months service contract. Said payment will be given upon the direct hiring of the caregiver. If the undersigned fails to pay and remit the payment within seven (7) working days,the non-payment will be given to our legal counsel for the due legal process of attention and collection.INDEMNIFYING CLAUSE: The undersigned fully understands that the provider (a) is a non-medical provider, (b) is not licensed to perform medical services, and (c) the undersigned, indemnify, jointly, and severally hereby forever release, discharge, acquit, and forgive any and all claims, actions, suits, demands, liabilities, judgment, and proceedings both at law and in equity, arising from the beginning of time to the date of termination of this agreement with the Agency Provider, such are caused directly by the negligent acts or omissions by the above items and “Services” and the “agency caregivers” and which result in bodily injury or property damage. This release shall be binding upon insured to benefit the parties, their successors, assigns and personal representatives.ATTORNEY’S FEES: In any cases of any litigation, in prevailing party the “Agency Provider” shall recover the cost and attorney’s fees arising from any lawsuits brought against the agency.Payment and Termination of Services: Payment is due at the time services have been rendered unless other arrangements have been made. Therefore, we reserve the right to suspend or discontinue services for non-payment of an account balance. You acknowledge that a valid credit card must always remain on file unless other arrangements have been made. Failure to do may result in your account being deactivated at our discretion.Acknowledgement of Appropriateness of Services: Please acknowledge that you can sit, walk and stand with minimal assistance and understand LinkCo health workers cannot carry or lift clients and do not provide personal care services, which include but not limited to bathing, grooming, toileting, dressing or feeding. Clients that are wheelchair bound must be able to self-transfer in and out of a non-wheelchair accessible vehicle using a transfer board or other equipment that can be stowed away safely in a regular vehicle during transport.Pricing:Current pricing as of 11/1/2025 is listed below but subject to change at any time and without notice.Medical Equipment and Devices: Please acknowledge that if you have a wheelchair, walker or rollator you understand these items must be collapsible and able to be stowed away safely in a non-wheelchair accessible vehicle such as a sedan, SUV or minivan.
🌿 LinkCo Community Guidelines
Creating a Caring and Respectful Experience — Together

At LinkCo, we believe every ride, visit, and interaction should reflect the compassion and professionalism that define our community. These guidelines are here to help both clients and caregivers enjoy a safe, comfortable, and positive experience every time.

🌟 1. Respect and Kindness Go a Long Way
We’re all part of one caring community. Please treat your companion driver or client with the same courtesy and understanding you’d want for yourself.

Be ready at your scheduled time it helps everyone stay on track.
Use kind, calm communication no shouting, harsh language, or raised voices.
Treat your driver’s or client’s personal space and property with care.
Practice good hygiene and tidiness leaving the space as pleasant as you found it.
A little kindness makes every trip and visit brighter.

🛡️ 2. Safety First, Always
Safety is a shared responsibility.

Always buckle up and follow local traffic laws.
Drivers must never text, use handheld phones, or drive under the influence of any substance (including certain medications) that may impair alertness.
Only authorized LinkCo riders and caregivers may be in the vehicle.
If you ever feel unsafe or notice anything unusual, please contact our LinkCo office immediately at (757) 802-4246.

💬 3. Feedback Builds a Better Community
We value your voice! Whether it’s a compliment, suggestion, or concern, your feedback helps us improve.

Positive feedback helps celebrate those who go above and beyond.
Constructive feedback allows us to address issues quickly and fairly.
If something happens during a ride or visit, please let us know right away so we can support you.
Your input keeps LinkCo caring, accountable, and continually improving.

❤️ 4. Protecting Our Community Standards
To maintain a safe and respectful environment, the following behaviors are not tolerated and may result in temporary suspension or permanent removal from the LinkCo community:

Damaging property or causing harm to a caregiver or client.
Using abusive, threatening, or discriminatory language or gestures.
Making unwanted personal contact after a visit or ride.
Engaging in fraud or misuse of promotions, duplicate accounts, or false reports.
Any form of discrimination based on race, color, religion, national origin, disability, sexual orientation, gender identity, age, or any other protected characteristic.

🤝 5. Accountability and Partnership
If an issue arises, our team will reach out to both parties to understand what happened and find a fair resolution.
Depending on the situation, we may place a temporary hold on service access while we review the matter. Repeated or serious violations can result in permanent removal from the LinkCo network.

Our goal is always to restore trust, ensure safety, and keep our community strong.

Together, We Create the LinkCo Difference
Every safe ride, kind word, and positive interaction helps us build a community rooted in care and respect. Thank you for being an essential part of the LinkCo family.

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Enrollment Form (Revised)

PERSONAL DETAILS

Contact Details Person Completing Form or Responsible Party

Contact Details of Care Receiver

EMERGENCY CONTACTS (KINDLY PROVIDE AT LEAST 2)

HEALTH DETAILS

CREDIT CARD AUTHORIZATION AND CONSENT FORM

CARD HOLDER INFORMATION

PAYMENT AUTHORIZATION