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OldCare Admission Form
Personal Information
Full Name *
Date of Birth *
Email Address *
Phone Number *
Emergency Contact Name *
Emergency Contact Number *
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Health and Medical History
Allergies
Current Medications
Primary Physician's Name *
Health Conditions
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Daily Living and Assistance Needs
Level of Independence *
Select
Independent
Needs Some Assistance
Full Assistance Required
Dietary Restrictions
Mobility Assistance Needed *
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No Assistance
Some Assistance Needed
Full Assistance Required
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Legal and Financial Documentation
Responsible Party for Financial Matters *
Power of Attorney *
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Yes
No
Insurance Information
Advance Directives *
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Living Will
Do Not Resuscitate (DNR)
None
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Review Your Details
Full Name:
Date of Birth:
Email:
Phone Number:
Allergies:
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