Application

Application for Residence
Date
MM slash DD slash YYYY
Applicant's Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone Number*
Email Address*
Date of Birth*
MM slash DD slash YYYY
Current Age*
Please enter a number from 18 to 150.
Social Security Number*
Marital Status*
- Single
- Married
- Widower
- Widow
Medicare Number
Other Health Insurance Information (name, address, and policy number)
Current Living Arrangements
Primary Care and/or Other Physician names and telephone numbers
Advance Directives
Do you have...*
- Power of Attorney
- Durable Power of Attorney
- Guardian
- Living Will
- None of the above
Guardian Name
First Last
Guardian Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Guardian Email*
Guardian Home Phone Number*
Guardian Work Phone Number*
Primary Contacts Information
Please list the names and addresses of your primary contacts (ex. family and emergency contacts)
Name*
First Last
Address*
Email Address*
Primary Phone*
Secondary Phone
Name
First Last
Address
Email Address
Primary Phone
Secondary Phone
Name
First Last
Address
Email Address
Home Phone
Work Phone
Medical Information
Current Medical Conditions/Diagnoses:*
Allergies (Food and/or Medication)
Current Medications and Administration Schedule:
Please include the medications, dosage, frequency, route, and *IF PRN, AVG, FREQ. GIVEN
Financial Information
We require proof that the resident has available assets that will allow him/her to stay at Sagepoint Gardens Assisted Living for at least one year. Please provide bank statements showing savings accounts, checking accounts, CDs, stocks, bonds, etc. that will verify this financial ability.
Monthly Income
Social Security #
Retirement
Other Income
I agree that if I am accepted as a resident of Sagepoint Family of Care (HomePlace) Assisted Living:
1. I recognize my financial obligation to pay all doctors fees, hospitalization charges, private duty nursing, and medication charges that I may require that are not covered by government or private insurance.
2. I will pay monthly, in advance, any charges for which I am responsible.
I hereby certify that all the above information and attached statements are accurate and correctly reflect the financial position of the resident.
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301.276.0130

Application for Residence

Advance Directives

Primary Contacts Information

Medical Information

Financial Information

Talk to a Sagepoint Advisor