Serenity Caregivers: Day Center Application

Serenity Caregivers Day Center Application
INSTRUCTIONS:

Fill out request information by printing or typing. (Attach pages if needed for additional information) Once complete, submit, mail, fax or email an application to the center. After receiving the application, the center will call and set up an appointment for a visit and for the applicant to be evaluated.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Sex*

MALEFEMALE
Date of Birth*

MonthDayYear
Date
With whom does applicant live with?*
Relationship to Applicant*
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Alternate Emergency Contact*
Alternate Emergency Contact Phone Number*
Please enter a valid phone number.
Alternate Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List any chronic illnesses and medical conditions*
Applicant Health History
List any chronic illnesses and medical conditions:*
Allergies*
Personal Physician Information
Physician's Name*
Office Phone Number*
Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Hospital*
Medicare/Insurance Information
Part A Claim Number
Part B Claim Number
Other Insurance Coverage Number
What Assistance is Required? (Select all that apply)*

WalkingStandingToiletingEatingNone
If any are selected above, please explain:
Food Allergies?
Diet:*

Regular DietDiabeticLow SodiumOther
Current Medications (include dosages and times given)*
Requesting Start Date*

MonthDayYear
Date
Days Requested to Come to Facility*
Times Requested to Come to Facility*
Is Transportation Assistance Needed?*

YESNO
If answer above is "No", who will by transporting the applicant?
Name of Individual or Agency Responsible for Payment of Services*
Address of Responsible Party*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Applicant signature*

Clear
Signature of Person Completing this Form*

Clear
Relationship to Applicant*
The Following will be agreed upon at the time of interview/evaluation:

1. Hourly Rate

2. Daily Rate

3. Weekly Rate
The Down Payment is due upon signing:*

I Agree
Should be Empty:

Serenity Caregivers Day Center Application

Applicant Health History

Personal Physician Information

Medicare/Insurance Information