assessment_request_form

Applicant's Full Name:

Birth Date:

Gender:

Male Female

Applicant Address:

Subject:

Marital Status:

Present Living Arrangements:

Medicaid#:

Medicare#:

Supplemental Security Income:

Tell us why you are interested in joining this program?:

Have you had previous experience in an adult day care program?:

Yes No

If yes, Where and when?:

Living with whom:

Relationship with whom their living:

Nearest responsible relative:

Relationship to nearest relative:

If employed, Where:

Business Phone:

Emergency Contact#1:

Applicant Relationship#1:

Emergency Address#1:

Emergency Phone#1:

Emergency Contact#2:

Applicant Relationship#2:

Emergency Address#2:

Emergency Phone#2:

Physician Name:

Physician Address:

Physician Phone:

Physician Last Visit:

Dentist Name:

Dentist Address:

Dentist Phone:

Dentist Last Visit:

Transportation will be provided by:

Arrive Time:

Departure Time:

Special Diet?:

Yes No

If yes, give details:

List all allergies:

Days and times requested to be at Blessed Assurance:

I acknowledge that the participation in this program will be paid by :

Give name of person/party responsible that is mentioned above:

Phone number of person to pay bill:

Email *

If emergency medical care becomes necessary, I give permission for any treatment the physician deems necessary. My hospital choice is:

But I (the applicant) may be treated at the nearest facility if the emergency deems it necessary.

By entering your full name, you are digitally signing this form:

Siga-nos

Siga-nos

Assessment Request Form