APPLICATION FOR RESIDENCY

Apply for Residency

Dear Potential Resident,

Thank-you for your interest in ExquisiCare.  We are the premier, boutique provider of fine long term care 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

Your Desired Home

Select from the list ... ON - Brampton: Brampton ON - Caledon: Caledon AB - Edmonton: Cameron Heights AB - Edmonton: Westcliff Place AB - Edmonton: Windermere Manor

Resident Name

Birthdate

Address

City

Province

Postal Code

Telephone

Gender

Male    Female

Occupation:

Marital Status

Married    Single    Widow/er

Preferred Language

Other Languages

Provincial Health #

Supplemental Heath Insurance:

Provider

Policy #

Provider

Policy #

Emergency Contact Information:

Name

Phone #

Address

Relationship

Current Living Situation

Please describe your current living situation:

Do you currently require someone to live with you or do you get help in your home?  If so, what type of help do you receive and how often?

Medical Information

Family Doctor Name

Phone #

Do you regularly visit any specialist physicians? If so, please list them and the frequency of your appointments:

Please list any medical conditions that you have:

Please list any surgeries you have had (including the year):

Please list all medications (including over the counter medications) that you take on a regular basis:

Do you regularly receive your seasonal influenza vaccination?

Yes    No

Have you ever been told you have an Antibiotic Resistant Organism?

Yes    No

Do you require regular lab work?

Yes    No

Height

Weight

Do you have any allergies?

Yes    No

If yes, please list:

Are you on a special or restricted diet?

Yes    No

If yes, please explain:

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

Are there any specific interests or hobbies you enjoy?

Do you have a Personal Directive?

Yes    No

Is there anything else you would like us to know about your situation or your health care needs?

Financial Information

Who will be responsible for the payment of bills?

Self    Someone Else    Joint

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

Name

Relationship

Address

City

Province

Postal Code

Phone

Email

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.

Name of Appliant/Power of Attorney

Date