Application For Admission

Tuesday, 15 June 2010 20:07 Written by Administrator

Personal History:

Thank you for choosing Port Charles Assisted Living in Charles City, Iowa.  We are very excited that you have chosen to look into Port Charles.  Please fill out the form below and read the instructions below the form.  If you have any questions at all please feel free to contact us.  We will be delighted to answer any and all questions you might have.  We will be making contact with you shortly after we have received your electronic application as well as your Health History.   For your security we ask that you download the Application Signature Page and either fax it into us or mail it to us.

Thank you,

Port Charles Administration

 

Application For Admission
Port Charles Assisted Living Application

Todays Date:

MM		/
DD		/
YYYY
First Name*
Middle Name*
Last Name*
Sex
Male 
Female 
Address*
Address*
Address*
Address*
Telephone Number*
Marital Status*
Married 
Single  
Widowed 
Divorced 
Choose one.
Your Age*
Birth Date

MM		/
DD		/
YYYY
Birth Place and State*
Spouse's Name, Address and Phone
Church Affiliation, Address and Phone Number
Pastors Name and Phone Number
Doctor's Name, Address and Phone Number
Dentist's Name, Address and Phone Number
Pharmacy Name, Address and Phone Number
Funeral Home Name:
Funeral Home Phone Number
Are You a Veteran?
Yes 
No 
Are you the spouse, widow or dependent of a
veteran?
Yes 
No 
In case of an emergency (list in order of
preference), please notify. List three.
Please list relationship, name, address and phone number for each.
Do you have a Living Will?
Yes 
No 
Power of Attorney - Health Decisions?
Yes 
No 
Do you have an automobile?
Yes 
No 
Approximate date of desired occupancy?*
Image Verification
captcha
Please enter the text from the image:
[Refresh Image][What's This?]

We will also need for you to fill out the other forms as well. Please continue by submitting this form and by filling out the other forms.

Login Form



Contact Information

Port Charles Assisted Living

801 Blunt Parkway * Charles City, Iowa 50616  * Phone: 641 257-3003  * Email: pcal@fiai.net * Web: pcalcc.com

Email Us

Site Login