Admissions Form - Parker Jewish Institute for Health Care and Rehabilitation

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Admissions Form

Name
Email
Home Telephone Number
Cell Number
Patient's / Resident's Name
Relationship to the Patient / Resident
Patient's / Resident's Present Location
Home Address
Nursing Home & Room / Floor Number
Hospital & Room / Floor Number
Seeking Admission For:
- Short Term Rehabilitation
- Long Term Care / Nursing Facility
- Home Health Care
- Hospice
- Social Day Care
- Medical House Calls
- Dialysis (provided by Queens-Long Island Renal Institute)
- Not Sure / Other
Comments: