Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone

(###)

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Date of Expected Visit *

MM

DD

YYYY

Time of Expected Visit *

Hour

Minute

Second

AM PM

Have you have any cough, cold, or flu symptoms in the last 14 days? *

Yes

No

Name *

First Name

Last Name

Phone *

(###)

###

####

Health, Safety, & Confidentiality During Your Visit *

At Gateway Holistic Care Group, the safety and security of our clients, staff, and visitors are of utmost importance. Our safety protocols are designed to create a secure environment that prioritizes well-being while supporting the independence and growth of our clients. All staff undergo thorough training in emergency response, first aid, and health and safety regulations. We regularly conduct fire drills, review evacuation procedures, and ensure that our facilities comply with all safety standards. Access to our premises is closely monitored, with visitors required to sign in and out, wear visitor badges, and adhere to supervised visitation guidelines. These measures ensure that only authorized individuals have access to our spaces, contributing to a safe and controlled environment. Our health policy requires all visitors to be symptom-free for a minimum of 24 hours prior to their visit to ensure the well-being of everyone on the premises. Visitors experiencing symptoms of illness such as fever, cough, or gastrointestinal distress are asked to reschedule their visit until they are fully recovered and symptom-free. This policy is a key component of our infection control strategy, helping us maintain a safe and healthy environment for our vulnerable clients. Our confidentiality policies also address the handling of any sensitive information or situations observed during a visit. Visitors are required to sign a confidentiality agreement before entering our facility, ensuring their understanding and commitment to safeguarding the privacy and dignity of our clients. Any information or incidents observed during a visit, such as client behavior, medical care, or personal details, must remain strictly confidential. Visitors are prohibited from discussing, recording, or sharing any information related to what they observe within the facility, including on social media or with unauthorized parties. This ensures that visitors respect the sensitive nature of our work and the trust placed in us by our clients and their families. By entering Gateway Holistic Care Group’s premises, do you understand, acknowledge, and agree to adhere to our policies regarding safety, health, confidentiality, and respectful conduct during your visit?

Yes - I understand, acknowledge, and agree to adhere to your policies regarding safety, health, confidentiality, and respectful conduct during my visit

Consent to Process Personal Data *

Gateway Holistic Care Group is committed to protecting your privacy and complying with applicable data protection regulations, including the General Data Protection Regulation (GDPR). By signing this form, you consent to the collection, processing, and storage of your personal data for the purposes of providing care services, maintaining records, and fulfilling contractual obligations. How Your Data Will Be Used - To provide tailored services and support. - To communicate with you regarding services, appointments, and updates. - To comply with legal and regulatory requirements. Your Rights You have the right to: - Access the personal data we hold about you. - Request corrections to any inaccuracies in your data. - Withdraw your consent at any time (this may affect our ability to provide certain services). Data Security Your personal data will be stored securely and will not be shared with third parties without your explicit consent, except where required by law.

By selecting this, you confirm that you understand how your data will be used and consent to Gateway Holistic Care Group processing your personal data as outlined above.