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Senior Residential Facility in Bedford, Ohio

APPLICATION Materials

Applicant’s Consent to Release Medical Information

I hereby authorize any physician, clinic or hospital to answer fully any request from Light of Hearts Villa for medical or psycho-social information concerning me as an applicant or while I am a Resident at Light of Hearts Villa.

"*" indicates required fields

Resident Name*
MM slash DD slash YYYY
Clear Signature
MM slash DD slash YYYY

Application for Admission – Part 1

Emergency Contact Information
Resident Information

(Please Print)

First Name*
M.I*
Last Name*
Preferred Name/Nickname
MM slash DD slash YYYY
Gender*
Marital Status
CURRENT ADDRESS*
Primary Doctor
Name*
ADDRESS*
Other Doctor or Specialist
Name
ADDRESS
Dentist
Name*
ADDRESS*
Primary Hospital
Hospital Name*
ADDRESS*
Funeral Home
Funeral Home Name
ADDRESS
Other Doctors’ Notes and Contact Information:

Names & Relationship of Immediate Contact(s)

If there is a legal guardian, please list the information and attach documentation to this form.

Name of Guardian
ADDRESS
Power of Attorney

Contact #1 will be the first contacted in case of an Emergency.

Contact #1
Billable Party:*
Durable POA:*
Healthcare POA:*
Name:
ADDRESS
Contact #2
Billable Party:
Durable POA:
Healthcare POA:
Name:
ADDRESS
Contact #3
Billable Party:
Durable POA:
Healthcare POA:
Name:
ADDRESS

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