Senior & Elder Care
Assisted Living Facility Admission Agreement
Admission agreement for assisted living facility covering care services, fees, resident rights, and discharge procedures. Two signers (facility and resident).
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# Assisted Living Facility Admission Agreement **Effective Date:** ___________ This Assisted Living Facility Admission Agreement ("Agreement") is entered into by and between: **Facility:** ___________ ("Facility") **Resident:** ___________ ("Resident") **Responsible Party (if applicable):** ___________ ## 1. Facility Information **Facility Address:** ___________ **License Number:** ___________ **Facility Administrator:** ___________ **Facility Phone:** ___________ ## 2. Resident Information **Date of Birth:** ___________ **Preferred Room Type:** ___________ **Assigned Room/Unit:** ___________ **Primary Physician:** ___________ **Known Medical Conditions:** ___________ **Allergies:** ___________ **Current Medications:** ___________ **Dietary Requirements:** ___________
Fields (36)
effective date
date · required
facility name
text · required
resident name
text · required
responsible party
text
facility address
textarea · required
license number
text · required
administrator name
text · required
facility phone
text · required
resident dob
date · required
room type
select · required
room number
text
primary physician
text · required
medical conditions
textarea · required
allergies
textarea
medications
textarea · required
dietary requirements
select · required
care level
select · required
additional services
textarea
move in date
date · required
monthly fee
text · required
care surcharge
text
community fee
text · required
security deposit
text · required
payment due
select · required
payment method
select · required
late fee
text · required
rate notice
select · required
care plan review
select · required
medical services
select · required
voluntary discharge notice
select · required
deposit return
select · required
governing state
select · required
facility signer name
text · required
facility signer title
text · required
resident signer name
text · required
signer relationship
text
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