Care Information Request Care Information Request Contact InfoName * Required First Last Email * Required Daytime Phone * RequiredHow should we contact you? * RequiredEmailPhoneCare InformationClient Name (if different): * Required First Last I am looking for care for: * RequiredMeMy SpouseMy ParentA Family MemberA FriendOtherCare will be provided in: * RequiredBurlingtonHalton HillsMiltonOakvilleWhat type of care are you looking for? * Required I'm not sure and I don't know where to start Personal Support Nursing Companionship Grocery Shopping Transportation to Appointments Meal Preparation Housekeeping Social Support Fall Prevention Hospice Care Dementia Care Private Respite Care Bereavement Support Anything else you'd like us to know?Permission to Submit * Required I agree Acclaim Health is committed to individual privacy and has taken reasonable precautions to ensure the security of the information you are submitting through this online form. By clicking "I agree" you are acknowledging and accepting the potential risks inherent in submitting personal information and/or personal health information online. Please contact us by telephone at 905-827-8800 if you do not wish to submit this information online and we will be happy to assist you.NameThis field is for validation purposes and should be left unchanged.