ian paradise
Personal Information
Full Name *
Date of Birth *
Age
Gender* --Select --MaleFemaleOther
Marital Status * --Select --SingleMarriedWidowedDivorced
Permanent Address *
Contact Number *
Your email*
Select Villas & Apartments
Select your Villas/Apartments ----- Select -----1 BHK Apartment2 BHK Apartment1 BHK Villa2 BHK Villa
Emergency Contact Details
Name of Primary Contact Person *
Relationship to Resident *
Address *
Contact Numbers
Phone No.*
Alternate Phone *
Email*
Medical Information
Blood Group *
Height (cm)
Weight (kg)
Doctor’s Name / Clinic:
Doctor’s Contact No
Current Health Status --Select --StableRequires AssistanceCritical Care Support
Any Chronic Conditions --Select --DiabetesHypertensionHeart DiseaseKidney DiseaseStrokeParkinson’sAlzheimer’sOthers
Current Medications
Allergies (if any)
Mobility Status --Select --IndependentRequires Walking AidWheelchairBedridden
Special Dietary Needs
FAMILY / GUARDIAN DETAILS
Guardian / Sponsor Name
Guardian Relationship
Guardian Address
Guardian Phone No
Guardian Email ID
Authorized to take decisions in medical emergencies: --Select --YesNo
TYPE OF CARE REQUIRED
Independent Assisted Living (no medical support)Assisted Living with Medical SupportShort-term Stay / Respite CareLong-term StayPost-Hospital RehabilitationMemory / Dementia Care
(Please tick all applicable options)
ROOM / FACILITY PREFERENCE
Single RoomDeluxe RoomCouple Room
Preferred Start Date
Preferred End Date
Duration of Stay
CONSENT AND DECLARATION I hereby declare that the above information is true and correct to the best of my knowledge. I authorize the Assisted Living Centre to provide care and support as per their policies. I also consent to emergency medical treatment if required.
