SABAHAY, Inc. — Client Service Request & Agreement

SABAHAY, Inc. — Client Service Request & Agreement

SABAHAY, Inc.

1769 Hillsdale Avenue #54252

San Jose, CA 95154

Phone: (650)520-9912

Email:  sabahay627@gmail.com

Website: sabahay.co

Non-Medical Care Logistics & Assistance • Serving Santa Clara County

Delivery • Pickup • Handling • Errands • Grocery Shopping


1. Client information
Client’s full name: __________________________________________ 

Preferred name: ______________________________________________

Phone: __________________________ 

Email: _____________________ 

Service address: _____________________________________________

Preferred way to contact you: ☐ Phone ☐ Text ☐ Email
Emergency contact (optional): _________________________________

Relationship: __________________ 

Phone: _______________________

2. Requested service
Please check all that apply:
☐ Delivery ☐ Pickup ☐ Handling ☐ Errand   ☐ Grocery shopping 

☐ Other non-medical assistance: ______________

What would you like done? Include relevant instructions:  

Requested date/time: ___________________ 

Is this recurring? ☐ No ☐ Yes 

If yes, preferred schedule: ____________________________________

3. Service limits and client instructions
Please list access or communication instructions relevant to the service. 

Do not include diagnoses, medication lists, insurance numbers, or other medical information.

For shopping or purchases, the client’s approved spending limit is $________.

☐ I will provide funds/payment in advance. 

☐ Please contact me for approval before purchases. 

☐ Other arrangement: _________________________________________

4. Estimate and payment
Service fee/rate: ___________________ Mileage/other fees: __________ 

Estimated total: $__________________ 

This is ☐ a fixed quote ☐ an estimate that may change with client approval.

Payment arrangement: ☐ Pay at booking ☐ Invoice after service 

Payment method: ☐ Online payment ☐ Other: ______________________

No unapproved purchases or additional services will be added to the bill. If the requested work or estimated cost changes, SABAHAY will seek the client’s approval before proceeding, except where an immediate safety concern requires contacting the client or designated contact.

5. What this service is—and is not—SABAHAY provides the specific non-medical errands, delivery, pickup, shopping, handling, and assistance agreed with the client. Services are arranged individually and are subject to confirmation by SABAHAY.

SABAHAY does not provide medical care, nursing, diagnosis, treatment, medication management, 

or emergency response under this agreement. For emergencies, call 911. Clients should contact their insurer or benefits administrator directly to ask whether any service is covered. 

SABAHAY does not promise insurance or benefit reimbursement.

6. Client approval
I confirm that the information and instructions I provided are accurate to the best of my knowledge. 

I have reviewed the requested services, estimated charges, and service limits above. 

I understand that work outside the agreed scope or spending limit requires my approval.

Client/authorized representative name: __________________________

Relationship, if applicable: ___________________________________

Signature: ______________________________ 

Date: ______________

SABAHAY representative: ___________________ 

Date: ______________

7. Service completion record—complete after service
Date/time completed: ___________________ 

Work performed: ______________________________________________  

Approved additional charges/expenses: __________________________ 

Final amount due: $__________________ 

☐ Client notified of completion ☐ Receipt/invoice provided

Client acknowledgment (optional): __________________ 

Date: _________________________