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. Wellness checks are for check-in on the status of 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 directly, please call Eddie Edwards @ 703-926-0244.
YOUR Full Name:
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First Name
Last Name
YOUR Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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
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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
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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.
Format: (000) 000-0000.
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