Application for Admission
Please answer all questions as accurately and completely as possible. All information will be held in strict confidence.
Please choose which Archbold Living facility you are applying to (you may choose more than one):
Archbold Living - Cairo
Archbold Living - Camilla
Archbold Living - Pelham
Archbold Living - Thomasville
Name
First Name
Last Name
Email
example@example.com
Gender
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Place of Birth
Marital Status
Widowed
Divorced
Single
Married
Separated
Name of Spouse
Mother's Maiden Name
Number of Children
Number of Children Living
Medical Insurace
Medicare
Medicaid
Other
If "Other," please list here
Medicare #
Medicaid #
Social Security Number
Monthly Income
Monthly Pension Income
In the section below, please fill out the information for your living children.
Child #1
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Alternative Phone Number
Please enter a valid phone number.
Child #2
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Alternative Phone Number
Please enter a valid phone number.
Child #3
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Alternative Phone Number
Please enter a valid phone number.
In the section below, please fill out the information for other close relatives.
Close Relative #1
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Alternative Phone Number
Please enter a valid phone number.
Close Relative #2
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Alternative Phone Number
Please enter a valid phone number.
Close Relative #3
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Alternative Phone Number
Please enter a valid phone number.
In case of serious illness or death, please list the people you would like to have notified.
Person #1
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Alternative Phone Number
Please enter a valid phone number.
Person #2
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Alternative Phone Number
Please enter a valid phone number.
Person #3
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Alternative Phone Number
Please enter a valid phone number.
Personal History
Where have you lived most of your life?
Your profession, trade, or occupation
Highest grade completed?
What are your hobbies?
Relationship with whom you are living now?
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Military Service?
Yes
No
If yes, please describe your service.
Number of Years of Service
Rank
Funeral Information
Funeral Home
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Church
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Personal History
Local Doctor
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Pharmacy
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Dentist
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Other Doctor
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Other Doctor
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Other Doctor
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Last Period of Hospitalization (date, location, doctor and illness)
Are you able to go about without assistance?
Yes
No
Comments
Can you dress yourself?
Yes
No
Comments
Have you ever been paralyzed?
Yes
No
Comments
Is there mental illness in your immediate family?
Yes
No
Comments
Can you care for your normal personal needs?
Yes
No
Comments
Do you have heart trouble?
Yes
No
Comments
Do you have cancer?
Yes
No
Comments
Do you have sores?
Yes
No
Comments
Do you have kidney trouble?
Yes
No
Comments
Do you have tuberculosis?
Yes
No
Comments
Do you have diabetes?
Yes
No
Comments
Do you have high blood pressure?
Yes
No
Comments
Have you ever been a patient in a mental hospital?
Yes
No
Comments
Any other diagnoses?
I make this application for admission into this facility of my own free will and accord. I declare the answers to the foregoing questions to be true, full and complete. I further acknowledge I have been fully informed of services available in the facility and related charges including any charges not covered under Titles XVII or XIX of the Social Security Act, that I will be transferred or discharged only for medical reasons or for my welfare or that of other residents; that I will be encouraged to exercise my rights as a resident and as a citizen to voice my grievances to facility staff and/or outside representatives of my choice; that I may manage my personal financial affairs or be given, at least quarterly, an accounting of financial transactions made on my behalf should the facility accept my written delegation of this responsibility; that I will be free from mental and physical abuse, free from chemical and (except in emergencies) physical restraints except as authorized in writing by my physician; that I may approve or refuse the release of my medical record to any individual outside the facility; except in case of transfer to another healthcare facility or as required by law or third party payment contract and that my personal and medical records will be treated with the strictest rules of confidentiality; that I will be treated with consideration, respect and full recognition of my dignity and individuality, including privacy in treatment and in care for my personal needs; that I will not be required to perform services for the facility that are not included for therapeutic purposes in my plan of care; that I may associate and communicate privately with persons of my choice, may send and receive mail unopened, unless medically contraindicated as documented by my physician in my medical record; that I may retain and use my personal clothing and possessions as space permits; that, if married, I will have privacy for visits by my spouse. The approved monthly reimbursement rate established by the Department of Human Resources is an inclusive rate to cover the cost of the following: [a] resident's room and board (including special diet when specifically prescribed by a physician), privacy shall be furnished in case of terminal illness; [b] laundry (including personal laundry); [c] nursing and routine services, routine services include all nursing services and supplies, other supplies and equipment related to the day-to-day care of the resident, items of service which are covered in routine services include the following: all nursing services (excluding private duty nurses) regardless of the condition of the resident, medical social services, physical therapy, restorative nursing care, tray service, bed rails, walkers, wheelchairs, incontinency care and incontinency pads, hand feedings, special mattresses and pads, massages, syringes, enemas, nursing supplies and dressings (other than items of personal comfort or cosmetic items), extra linens, assistance in personal care and grooming, laboratory procedures not requiring laboratory personnel, non-prescription drugs to include aspirin, milk of magnesia, mineral oil, rubbing alcohol, prophylaxis medications (i.e. influenza vaccine, etc.). Physicians' services are not included. Prescription drugs are not furnished, but are obtained from a local drug store of the resident's choice.
Signature
Submit
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