Inquiry Form

Park Place Assisted Living Inquiry Form.

Please fill out this form to provide us with information regarding a potential resident. When finished click submit and the form will be emailed to us.

Your name:

Relationship to potential resident:

Your address:

Phone number:

Email:

Name of potential resident:

Age:

Current address:

Phone:

Smoker

Yes

No

Pet

Yes

No

Type of pet:

Resident needs assistance with: (check all that apply)

Bathing

Dressing

Medication Management

Personal Hygiene (brushing teeth, combing hair, etc.)

Ambulation

Meal Reminders

Orientation

Laundry

List of medications, health problems we should be aware of:

Please list medications and health issues such as diabetes, Parkinson's, dementia diagnosis, recent surgeries or illness.

How soon is potential resident planning to move?

Pay source:

Private pay

Medicaid

Enrolled or approved for Medicaid benefits?

Yes

No

Interested in coming for lunch and/or tour?

Yes

No

Comments:

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