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Service Request Form

Personal Information

Who needs this care?
Care recipient information
Please enter a valid first name
Please enter a valid last name
Please enter a valid city
Please enter a valid postal code (e.g. A1A1A1)
Contact Person Information: Contact information:
Please enter a valid first name
Please enter a valid last name
Please enter a valid city
Please enter a valid postal code (e.g. A1A1A1)
Please enter a valid email
Please enter a valid phone number

Payment method

Please enter a valid first name
Please enter a valid last name
Please enter a 5-digit transit code
Please enter a 3-digit bank code
Please enter a valid bank account number

Billing information

Service request

Your service region is : {{order.service.region}}

Your SDC is : {{order.service.selectedSDC}}

Please select your service region:

Requested service(s) to be provided:

*Check all that applies

Schedule appointment
Please enter a date in future
per

Review

Contact Person Information

Name:
{{order.applicant.lastname}}, {{order.applicant.firstname}}
Address:
{{order.applicant.address}}, {{order.applicant.city}}
{{order.applicant.postalCode}} {{order.applicant.province}}
Email:
{{order.applicant.emailAddress}}
Phone number:
{{order.applicant.phoneNumber}}

Care recipient information

Name:
{{order.careRecipient.lastname}}, {{order.careRecipient.firstname}}
Address:
{{order.careRecipient.address}}, {{order.careRecipient.city}}
{{order.careRecipient.postalCode}} {{order.careRecipient.province}}

Payment method

Visa/master
Our service coordinator will contact you via phone and collect your credit card information directly.
EFT/Debit
 
Card holder's name:
{{order.billing.ref2}}, {{order.billing.ref1}}
Bank:
{{order.billing.ref3}}
Transit code:
{{order.billing.ref4}}
Bank code:
{{order.billing.ref5}}
Bank account number:
{{order.billing.ref6}}
My online account
Once you receive your invoice, please visit https://myaccount.sehc.com to pay with your credit card online.
Bill payment
Once you receive your invoice, please contact your financial institution for any inquiries.

Service

Selected service(s):
  • {{item}}
Estimated service start date:
{{order.service.startDateObj.toLocaleDateString()}}
Estimated hours of service/week:
{{order.service.serviceFrequency}} hrs/week

Confirmation

In order to confirm this service request, you must book a brief call with one of our coordinators. Service will not commence until this call has occurred.

Please add all times that suit your schedule for a coordinator to call you.


Identity verification

Information provided on this page is only for us to verifying your identity. We will use the method that you have chosen for payment.

Click here if you would like to update the card number, expiry date and security code.
In order to confirm this service, please read and agree to the terms and services.
 

Terms and Services

I agree to the above terms and services
Submit
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