Guest Application Form

Please complete the following guest application form for the Blue Lotus Residential Care Center.

Guest First Name(s)

Guest Surname

Date of Birth

Gender

Male Female

Status

Single Married Divorced Widowed

Nationality

Passport Number or ID Card Number

Email Address

Drug Allergies

No Yes

Please Specify

Blood Group (if known)

Emergency Contact Name

Relationship

Address

Contact Number

Proposed Date of Admission

Documents required for Admission Eligibilty Assessment (see list below)

Acceptance Statement

I hereby certify that my personal data given to Blue Lotus Care Center are true and correct. I give permission to Blue Lotus Care Center to take my picture in order to keep as a record and medical purpose. If any incorrect or faulty data are found, I will be solely responsible for all damages and negative consequences that may be caused to any third party and I hereby authorize the Center’s staff to enter my room using a master key in the event that I request assistance by phone or if I activate the emergency call button.

Signed by Guest/Relative

Documents required for Admission Eligibility Assessment

The following documents are required prior to admission, for our nursing and medical team to assess admission eligibility and to institute an appropriate care plan according to your medical needs. All medical documents should be dated no earlier than six (6) months from the intended date of admission.

Chest X-Ray Report
Completed Barthel Index Form
Recent medical documents (e.g. discharge summary/ in-patient summary from hospital, or memo from your General Practitioner)
List of your current medications (if applicable).