FRANCISCAN CARE CENTER, SYLVANIA ADMISSION INQUIRY FORM

Thank you for you interest in Franciscan Care Center, Sylvania.  By completing and submitting this form, information about the prospective will be reviewed by the Care Center Addmission Committee.

Prospective Resident

First Name:      Middle Initial:      Last Name:  Marital Status:   Married Single Widowed Divorced Home Address:      Phone:  City:      State:      Zip:      Birthday:

Responsible Party

First Name:      Middle Initial:      Last Name:  Home Address:      Home Phone:  City:      State:      Zip:      Birthday:  Work Phone:     Cell: Prospective resident currently at: Home     Assisted living Hospital     Nursing facility How did you find out about Franciscan Care Center? Newspaper     Radio Presentation     Other Please list any nursing home(s) and date(s) Resident was admitted to within the past calendar year: Prospective resident's current condition (Check all those which apply): Alert Forgetful Confused Demanding Cooperative Uncooperative Combative Feeds self Needs assistance eating Walks alone Walks with assistance Uses wheelchair or walker In chair/bed most of the time Dresses self Needs assistance dressing Blind Deaf Incontinent Diagnosis:     Physician: Allergies:     Phone number: Current medications: Additional medical/psychological problems: Pay status (Please check one):  Private pay     Medicare     Medicaid Please provide copies of medical insurance cards for verification before admission.

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