APPLICATION - PERSONAL INFORMATION
Application Received: _____________
(for entry by St. Simeon's)
PLACEMENT
DAY SERVICES

COTTAGE LIVING

HEALTH CARE CENTER
      Private
      Semi-Private
   ASSISTED LIVING
      Private
      Semi-Private

ALZHEIMER'S/MEMORY
      Private
      Semi-Private		  

NEW EXPANSION
Please indicate any of the following documents that have been completed and provide copies of each.
D.N.R. CONSENT

ADVANCE DIRECTIVE FOR HEALTHCARE

GUARDIANSHIP (Name) __________________________________________

POWER OF ATTORNEY (Name)  _____________________________________
PERSONAL INFORMATION
Last Name _______________________ First __________________  Middle _________________
SS# __________________   Marital Status ___________   Spouse's Name __________________
Home Address ______________________ City/ST _______________________ Zip ___________
Telephone ________________________   Date of Birth ________________  Age _____  Sex ___
Previous Occupation ______________________________ Employer _______________________
Have any family members resided at Saint Simeon's?  Yes   No
Name ______________________________________ Relationship ________________________
RELIGIOUS INFORMATION
Religious Affilation _______________________________________________________________
Name of Church/Clergy ___________________________ Telephone _______________________
Address __________________________ City/ST ___________________ Zip ________________
Name of Funeral Home ___________________________ Telephone _______________________
Address __________________________ City/ST ___________________ Zip ________________
IN CASE OF EMERGENCY (NEXT OF KIN)
Full Name ____________________________________ Relationship _______________________
Address __________________________ City/ST ___________________ Zip ________________
Bus. Phone ________________ Home Phone _________________ Cell Phone _______________
Email Address __________________________________________________________________
Full Name ____________________________________ Relationship _______________________
Address __________________________ City/ST ___________________ Zip ________________
Bus. Phone ________________ Home Phone _________________ Cell Phone _______________
Email Address __________________________________________________________________

MEDICAL INFORMATION
Diagnosis ______________________________________________________________________
Known Allergies ________________________________________________________________
Attending Physician __________________________________ Telephone ___________________
Address __________________________ City/ST ___________________ Zip ________________
Dentist ________________________________________ Telephone _______________________
Pharmacy ______________________________________ Telephone _______________________
Hospital Preference ______________________________________________________________
EMSA TotalCare   Yes   No
RESPONSIBLE PARTY
Full Name ______________________________________________________________________
Address __________________________ City/ST ___________________ Zip ________________
Bus. Phone ________________ Home Phone _________________ Cell Phone _______________
Email Address __________________________________________________________________
INSURANCE INFORMATION
Medicare Name (from card) ________________________________________________________
Medicare Number  _______________________________________________________________
Secondary Insurance  _____________________________________________________________
Policy Number ______________________________  Group Number _______________________
WHO REFERRED YOU TO SAINT SIMEON'S?
Name  ________________________________________________________________________
Address  ______________________________________________________________________
Phone ________________________________________________________________________
PLEASE INDICATE HOW YOU HAVE HEARD ABOUT SAINT SIMEON'S (check all that apply)
Physician
Website
Friend
 Hospital Personnel
Yellow Page Listing
Life Senior Services
 Case Manager
Magazine Ad
Newspaper
 Adult Day Services
Relative of a Resident
Alzheimer's Association
 Church
Radio Ad
Other _____________________________________
I certify that this application is made of my own free will and volition and that the information is correct to the best of my knowledge. I authorize and request that my attending physician, surgeon or other persons having direct, professional knowledge of my physical or mental health, past or present, provide to the staff of Saint Simeon's Episcopal Home any and all information relative to this application.

__________________________________________
Applicant or Representative
 ________________
Date
__________________________________________
Relationship
PRINT THESE PAGES and deliver via mail or fax to:
Saint Simeon's Episcopal Home
3701 North Cincinnati
Tulsa, Oklahoma 74106
Phone: 918.425.3583
Fax: 918.425.6368