senior care edmonton

Become a Resident

Dear Potential Resident,

Thank-you for your interest in ExquisiCare.  We are the premier, boutique provider of fine supportive living homes for seniors. In order to assess your suitability for residency in one of our homes, we ask potential residents to complete an Application for Residency.

This form is designed to help us begin to better understand you, your care needs and your preferences. We realize that many of the questions are of a personal nature.  Your information will be regarded as privileged communication and will be treated with confidence, in accordance with all applicable legislation.  Please ensure the information provided is complete and accurate so that we may make an informed decision about our ability to provide you with safe and quality care.

We look forward to reviewing your information and will be in contact with you to discuss our service philosophy and your application.

Kind regards,
ExquisiCare Inc.

General Information

   


       


Supplemental Heath Insurance:

Emergency Contact Information:


Current Living Situation


Medical Information

   
   
   


   


   

Assistance with Activities of Daily Living

Task I can do this independently. I require some assistance. I require total assistance Comments
Dressing
Oral Care
Bathing
Eating
Toileting
Grooming
Walking
Transferring
Medications

Additional Information

   

Financial Information

       

If someone else will be responsible for your bills, please provide their contact information:

I understand and agree that this application is neither a contract, nor a reservation for residence, but acknowledge and agree that the accuracy of the information contained herein is being relied on by ExquisiCare Inc.  to determine my suitability for residence in one of its facilities.  Nothing contained in these documents is legally binding on me or the company to which I am applying for residency, until such time as a Residential Service Agreement has been approved and signed by all parties.