Healthcare Senior Living Document

Senior Living Admission & Consent Form

Resident Information

Date of Birth:    Gender: Female Male Other/Prefer not to say

Insurance & Billing

Medical History & Care Needs

Primary Care Physician:    Phone:

Mobility: Independent Uses assistive device Requires assistance

Consents & Authorizations

Consent for Routine Care: I authorize facility staff to provide routine personal care, assistance with activities of daily living, and to arrange routine medical and rehabilitative services as needed in accordance with individualized care plans. I understand I may withdraw this consent at any time by providing written notice to administration.

Medication Administration: I authorize facility personnel to assist with or administer prescribed medications, including topical and oral medications, under standing orders or direct instruction from my prescribing clinician. I acknowledge that medication administration will be documented in my medical record and that controlled medications will be managed according to facility policy.

Vaccination & Treatment Consent: I consent to receive routine immunizations and influenza/COVID-19 vaccinations recommended by my clinician while a resident.

Transportation & Non-Emergent Medical Appointments: I authorize facility-arranged non-emergent transportation and staff accompaniment for medical appointments.

HIPAA Authorization & Privacy

I acknowledge that I have received and reviewed the facility's Notice of Privacy Practices describing the uses and disclosures of my protected health information. By signing below I authorize disclosure of my protected health information to the following individuals for purposes of care coordination, billing, and emergency contact:

Authorization Expiration Date:    Or check if authorization is valid until revoked:

Advance Directives & Legal Authority

Advance Directive / Power of Attorney: Does the resident have an advance directive or healthcare power of attorney on file? Yes No

Do Not Resuscitate / Physician Orders for Life-Sustaining Treatment (POLST/DNR): On file Not on file

Photo, Video & Research Consent

I authorize the facility to take photographs or video of the resident for care documentation, identification, and internal care planning. I understand that any use beyond internal clinical use (including promotional use) will require separate, specific written consent.

Consent to Photograph/Video: Yes    No

Acknowledgments & Facility Policies

I acknowledge that the facility will develop an individualized care plan based on assessed needs, that I will be consulted regarding the plan, and that facility staff will document all care, medications, and changes in condition. I agree to cooperate with recommended care and to provide current information about my medical history and medications.

I understand the facility's obligation to report communicable diseases and to take necessary infection control actions to protect residents and staff. I agree to follow facility policies related to visitation, infection control, and resident safety.

Certification

By signing below I certify that the information provided on this form is true and complete to the best of my knowledge. I authorize the facility to obtain medical records and communicate with healthcare providers as necessary for my care. I understand that falsification or withholding of information may affect the facility's ability to provide appropriate care.

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