Wellness Check Request
IF THIS IS A Medical or other EMERGENCY PLEASE CONTACT 911 IMMEDIATELY! Use this form to request a Wellness Check on a Resident. We can not provide Medical Advice or any assistance with medical diagnosis or care. Their Healthcare Provider must be contacted. We can not assist with any property or building issues. These must be addressed by the resident / homeowner. Wellness checks are for check-in on the status of a resident. We can not guarantee we will be able to call, visit or check-in on a resident. The Wellness Committee is a group of volunteers trying to keep an eye on residents who may have specific needs that a volunteer may be able to assist with. If you need to contact our Wellness Chairman please call Lori Wroblewski at 410 978 1727
YOUR Full Name:
*
First Name
Last Name
YOUR Phone Number
*
Please enter a valid phone number.
YOUR EMAIL ADDRESS
*
example@example.com
Reason for Check :
Not been able to reach (call 911 if serious concern)
Could use help getting to Store or Doctor
Feeling lonely / depressed
Needs occasional visit for well being
Other
Please list any concerns or issues we should be aware of
Resident needing Wellness Check
*
First Name
Last Name
Age of Resident
Estimated number of years as Resident
Full or Part Time
Full Time
Part Time
Resident needing Wellness Check Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of Resident that need check
*
Please enter a valid phone number.
Print Form
Submit
Clear Form
Should be Empty: