Agreement for Payment of Services - (PRIVATE PAY MEALS)
Home Delivered Meals
I have requested home delivered meals to assist with the nutritional needs of an individual. These meals are frozen meals that can be reheated in the microwave or conventional oven. Meals are $5.50 each and are packaged in the options below. Please begin deliveries on the week of _____/_____/_____.
I would like the following delivered:
ONE 2-Meal Box ($11.00) weekly
ONE 5-Meal Box ($27.50) weekly
ONE 2-Meal Box and ONE 5-Meal Box ($35.00) weekly
***** 2 Individuals in same home—
TWO 5-meal boxes ($40.00 weekly)
Meals Should Be Delivered To:
Recipient’s Phone #:_____________________________________________________
Directions To Home: _________________________________________________________________________
Please Invoice Monthly To:
All checks should be made payable to Vital Aging. I understand if a monthly invoice is not paid within 10 days; meal deliveries will be stopped and I will be responsible for any meals previously delivered. I must call Vital Aging at 354-5496 one week in advance to cancel this agreement and stop meal deliveries.
Please return form to: PO Box 450 Kingstree, SC 29556