Telephone Number (required)
Home Address (required)
Address Prior to Admission
Date of Birth (required)
Marital Status (required)
Last 4 of Social Security Number
Medicare Prescription Drug Plan (if applicable)
Has applicant applied for Medicaid/County Assistance?
Medicaid Billing Number: (if applicable)
Funeral Home Preference
Funeral Home Telephone Number
Church Telephone Number
Does the applicant have any of the following?:
Durable Power of Attorney for Finances
Please provide copies at time of admission.
List the name of children, other family, or significant others. List primary contact/DPOA or guardian FIRST. Statement should be sent (if different from primary contact below):
Family Contact #1 (Primary Contact/DPOA or Guardian)
Home Telephone Number
Work Telephone Number
Family Contact #2
Family Contact #3
Family Contact #4
Family Contact #5
Family Contact #6
Please note whether each condition is something applicant is currently dealing with, historical or not applicable. Give approximate dates condition occurred if possible and specifics as applicable (i.e. allergies-penicillin). Additional space is provided below if you need more space for explanation or to note problems/conditions not listed here.
Congestive Heart Failure
---ClearMild Memory ImpairmentModerate Memory ImpairmentSevere Memory Impairment
Problems with Vision
Problems with Hearing
Problems with Speech
Appliances Used (Check all that apply):
Alcohol and or Other Drug Abuse
Physical Abusive Behaviors/Aggression
Suicidal Ideations or Attempt
Non-Compliance with Medication Use
List additional information and or needs here:
Mother’s Name (First & Maiden)
List names of living and deceased brothers & sisters
Highest grade of education completed (list and degrees, colleges attended)
Date of Retirement (From Where)
Are you a veteran? (Give dates/branch of service)
Does the applicant receive VA benefits?
Marital Information (If Applicable)
Date of Marriage (Spouse 1)
Spouse’s Name(s)/Maiden (Spouse 1)
Date of Death/Divorce (Spouse 1)
Date of Marriage (Spouse 2)
Spouse’s Name(s)/Maiden (Spouse 2)
Date of Death/Divorce (Spouse 2)
Date of Marriage (Spouse 3)
Spouse’s Name(s)/Maiden (Spouse 3)
Date of Death/Divorce (Spouse 3)
List names of children and note those that are living and deceased
Other Significant Relationships
Past or Present Hobbies/Pastimes
Past or Present Involvement in Organizations, Groups, Clubs, etc.
Special Accomplishments, Awards Earned, etc.
Disclaimer and Acceptance
I agree to be responsible for payment of expenses from the applicant/resident’s funds. If payments are two months late, I agree that the outstanding balance shall bear monthly interest at the two points above the prime rate then being published in the Wall Street Journal effective January first of the current year until the full amount is paid. The party or parties executing this agreement shall be personally liable for any remaining balance due on the account upon the death of the resident, and such party or parties agree to indemnify and hold harmless Fairlawn Haven Nursing Home against any expense incurred in the collection of such balance. Estimated length of time resident will be able to private pay nursing home expenses.
Fairlawn Haven Care Center is not-for-profit and is Medicaid/Medicare approved. If you have limited resources, you may qualify for benefits through the County Job and Family Services@ 419-337-0010.
OUR LIFE CARE AGREEMENT. NO PERSON SHALL BE DISCHARGED FOR LACK OF FUNDS.
If admitted, I promise to do all within my power to promote a pleasant atmosphere in the Home, and comply with all rules and regulations of the Home.
Please check the box below to indicate your acceptance of the terms and conditions. (required)
Please check the box below to confirm that you are authorized to complete this application and provide this detailed medical and personal information. (required)
Name of Applicant or Legal Representation
Prove to us you're a human. Please type the text from the image in the field below:
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