Application for Admission
MM slash DD slash YYYY
please provide the full name and phone number.
Please list the names and addresses of your children.
Please Note: If your current physician does not have admitting privileges with Sagepoint Care Center, you will need to select another physician from our admitting list prior to admission.
Prior to Admission
Please provide us with copies of the following items:
Arrangements must me made with a funeral home. Please provide us with the name and address of your funeral home.
Enter the phone number of the funeral home.
In the event of an emergency, please list two people whom we should contact, in the order that you wish them to be called.
The following information must be provided, regardless of pay source.
I agree, that if I am accepted as a resident of Sagepoint:
- Should the need arise, I will change rooms based on the needs of the facility.
- I recognize my financial obligation to pay all doctors fees, hospitalization charges, private duty nursing, and medication charges which I may require that are not covered by state and federal programs.
- I will pay monthly, in advance, any charges for which I am responsible.
- If my condition becomes such that in the judgment of the health professionals at Sagepoint, I can best be cared for elsewhere, I will accept their recommendation.
I hereby certify that all of the above information is accurate. I give my permission for representatives of
Sagepoint to obtain verification of the information given above.