SERVICE AGREEMENT & CONSENT FORM

Client Name: ________________________________ Date: _______________________

1. SERVICES PROVIDED
Services include:
-
-
-
Other: ________________________________________________________________
Service Preferences: Preferred Days/Times: _______________________________________
Special Requirements/Accommodations: _________________________________________
Language Preferences: _____________ Mobility/Accessibility Needs: ___________________
Please note: Medical care, administering medications, or personal hygiene support are not provided.

2. RATES & PAYMENTS
Service Type: ☐ One-Time ☐ Weekly ☐ Monthly

• Individual Sessions:

Package Selected:
☐ Companionship
☐ Tech & Admin Support
☐ Home & Lifestyle Support
☐ Enriched Support
Hourly Rate: $___________ Total Hours Booked: ___________
Total: $____________ + HST = $___________________

• Monthly Subscription:

Package Selected:
☐ Starter (8 hrs/month) - $ /month
☐ Professional (12 hrs/month) - $ /month
☐ Business (20 hrs/month) - $/month
Hourly Rate: $___________ Total: $____________ (includes HST)

Payment Due:
☐ After session
☐ Weekly
☐ Monthly Auto-Renewal
Accepted Payment: ☐ E-transfer ☐ Cash ☐ Credit Card ☐ Other: _________
Billing Address (if different from service address): _____________________________
Cancellation Policy: Please provide 24 hours’ notice to cancel

Service Start Date:_______________________


3. CLIENT RESPONSIBILITY & CONSENT
I understand and agree that:

• I am voluntarily choosing to use the services of NewBridge Support
• I may decline any service at any time
• All information I share is confidential and protected under the Personal Health Information Protection Act (PHIPA)
• NewBridge Support providers are not licensed medical or nursing professionals
• Services may be discontinued by either party with 7 days’ written notice
• Unused subscription hours may be carried forward for up to 3 months, unless otherwise specified
• I will provide a safe and appropriate working environment for service providers
• Pets will be secured during service visits, where applicable
• I consent to NewBridge Support contacting my emergency contact or healthcare providers if reasonably required for my safety or care coordination

Health & Safety Information
Health Conditions/Allergies to be aware of: ______________________________________
Current Medications: _____________________________________________________
Other Safety Considerations: ________________________________________________

4. PRIVACY & CONFIDENTIALITY
All personal and health-related information will be protected under Ontario’s PHIPA legislation.
Your information will never be shared without written or verbal consent, unless required by law
or in case of emergency.

5. LIABILITY & INSURANCE
I acknowledge that NewBridge Support maintains liability insurance. I agree to hold harmless NewBridge Support from any claims, accidents, or injuries that do not result from its negligence. NewBridge Support is not responsible for any pre-existing conditions or health emergencies unrelated to the services provided.

6. ACKNOWLEDGMENT & SIGNATURE
I confirm that I have read, understood, and agree to the terms outlined in this agreement.

Client or Authorized Representative Signature: ___________________________

Printed Name: ________________________ Date: __________________


NewBridge Support Representative Signature: ____________________________

Printed Name: ________________________ Date: __________________
This agreement becomes effective upon signature and remains valid until terminated by either
party with appropriate notice as outlined above.



Form Version: 2.0 | Last Updated: August 11,2025