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Why Mx3P
Our Company
Who We Are
Our Impact
Training
Login
Register
Why Mx3P
Our Company
Who We Are
Our Impact
Training
Login
Register
Care Service Order
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Who What your
Name
*
First
Last
Email
*
Phone Number
*
What type of care are you interested in?
*
In-home care
Live-in
24/7 Home Care
What kind of help are you looking for?
Personal Care (Help with bathing, dressing, grooming, and personal hygiene)
Companionship (Providing emotional support and engaging in activities)
Housekeeping (Maintaining a clean and safe living environment)
Meal (Nutritious meal planning and cooking)
Transportation
Which language would you like your provider to speak?
*
English
French
Spanish
Haitian Creole
Persian
Portugees
When do you need the care service? (Date & Time)
*
Who needs a care service?
My parent
My spouse
My grandparent
My friend/extended relative
myself
Patient Gender
Female
Male
Other
Patient Age
Selected Value:
70
What should we know about them and consider about the care providers?
*
Example: Do they have any underlygin condition. What are their hobbies/interest?
Debit/Credit Card
*
Confirmation
*
I acknowledge that I have read and agree to abide by the the Terms and Conditions
I acknowledge that upon submitting this form, my orders are final and can no longer be canceled
Submit
