Assisted Living
Golden Star Residential Care Home
Rio Vista, California








SEND QUERY APPLICATION FORM

Application Form (No obligation/hassle. Help us to supply the information you need)

We will not share the information that you provide to us with anybody else. Please note our Privacy Policy (below).

Please fill in the fields below and then press the Submit button.

  Your First Name:  
  Your Last Name:  
  Your E-Mail Address:  
  Your Telephone Number:  
  How would you like us to contact you?  Telephone     Email
 
  Applicant's Full Name:  
  Applicant's Age (Years):  
  Is the applicant taking any medication?  Yes     No
  If you answered Yes to the previous question:  
      - Can the applicant manage their any medication? Yes     No     Not Applicable
  Is the applicant using any medical equipment?  Yes     No

  If you answered Yes to the previous question:
     -  Can the applicant manage their own medical equipment?  Yes     No     Not Applicable
  Is the applicant ambulatory?  Yes     No

  If you answered No to the previous question:
     -  Can the applicant feed themself? Yes     No
     -  Does the applicant need assistance dressing? Yes     No
     -  Does the applicant need assistance in the bathroom? Yes     No
     -  Can the applicant walk unassisted? Yes     No
     -  Can the applicant get in and out of bed unassisted? Yes     No
 
  Is the applicant suffering from Mild Cognitive Impairment?  Yes     No
  Is the applicant suffering from Dementia?  Yes     No
  Do you have a completed Physician's Report for RCFEs?  Yes     No
  Is the applicant an SSI recipient by RCEB?  Yes     No
  When would the applicant like to move in?:  

  Comments: