Nursing Home Inquiry Form
Nursing Home Inquiry Form
Kindly complete the form provided, using the specific information that is detailed below.
Name
Phone number
Preferred Method of Contact
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Phone
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Email
Resident Information
Name of Prospective Resident
Date of Birth
Current Address
Health Concerns/Conditions
Brief description of current health concerns.
Services and Amenities
In this section, please review the services and amenities offered at our facility. For each inquiry, choose or offer specifics that align with the resident's needs and preferences.
Medical Care
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24/7 Skilled Nursing Care: Around-the-clock nursing care by trained professionals.
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On-site Medical Doctor Visits: Regular visits by a licensed physician.
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Medication Management: Supervised medication administration and monitoring.
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Chronic Disease Management: Specialized care for conditions such as diabetes and hypertension.
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Emergency Medical Services: Immediate access to emergency medical care and support.
Therapy Services
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Physical Therapy
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Occupational Therapy
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Speech Therapy
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Recreational Therapy
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Pain Management Therapy
Daily Living Assistance
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Personal Hygiene Support
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Meal Assistance
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Mobility Support
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Housekeeping Services
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Laundry Services
Social and Recreational Activities
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Group Activities: Engaging in arts and crafts, games, and social events.
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Fitness Programs: Exercise classes and activities tailored to resident capabilities.
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Cultural Outings: Organized trips to local attractions and cultural events.
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Music Therapy: Participation in music sessions and therapeutic musical activities.
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Educational Workshops: Classes and seminars on various topics of interest.
Dining Services
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Nutritious Meals
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Special Dietary Options
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In-room Dining
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Social Dining Experiences
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Snack and Beverage Services
Name:
Date:
Thank you for submission!
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