Welcome To Grand Court Lakes

Quick Admit

Personal Information:

How Did You Hear About Our Facility?

Name:

Relationship:

Address:

City:

State:

Zipcode:

Phone:

()- -

Cell: ()- -

Email:

Name of Prospective Resident:

Current Address:

When Is The Perspective Resident Planning To Move In?:

Please check which best applies to the perspective resident:

Has the prospective resident been diagnosed with dementia/Alzheimer's? YES NO

Does prospective resident need any of the following?

Supervision, monitoring and assistance with activities and daily living: YES NO

Supervision with personal grooming, dressing and bathing: YES NO

Daily medication management: YES NO

Assistance with showering, bathing and or personal grooming: YES NO

Assistance with incontinence management: YES NO

Daytime, evening and night time checks to monitor resident: YES NO

Daily assistance with ambulation and transferring to and from wheelchair: YES NO

Daily assistance getting to and from dinning room and activities: YES NO

Daily assistance with feeding at meal times: YES NO