Free Trial Day Free Trial Day You must have JavaScript enabled to use this form. Your Information First Name Last Name Phone # Address Address Address 2 City/Town State/Province – None –AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Sex Age Race Marital Status Preferred Hospital Emergency Contacts First Emergency Contact Name Phone # Cell # Second Emergency Contact Name Phone # Cell # Physician Information Name Phone # Fax # Address Address City/Town State/Province – None –AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Standing Orders Please check the box either approving or declining action. Tylenol 350mg 1 or 2 tablets every 4 hours as needed for pain or fever – Select –YesNo Maalox 30cc every 4 hrs as needed for upset stomach – Select –YesNo Over the count cough drop every 4 hours as needed for indigestion/heartburn – Select –YesNo TUMS 1 or 2 tabs every 4 hours as needed for indigestion/heartburn – Select –YesNo Ibuprofen 200mg 1 or 2 tablets every 4 hrs as need for pain or fever – Select –YesNo Blood Sugar finger stick test as needed for signs/symptoms of hyper/hypo-glycemia – Select –YesNo Are you diabetic? – Select –YesNo Minor wound care as needed—cleanse with soap & water, apply antibiotic and dressing – Select –YesNo Medical Emergency Information Food Allergies Medication Allergies Medical Diagnosis History Medication / Dosage / Instructions Please list all your medications, dosage and instructions. What is your main reason for wanting to attend the Gilcrest Center? Who lives in your house? Do you have any pets? What are your favorite foods? What foods do you not like? What activities do you enjoy? Do you use any adaptive equipment? If so, please list. Wheelchairs, walkers, etc. Signature Disclaimer text goes here… I authorize….. Authorization Reset Sign above. Date Submit
You must have JavaScript enabled to use this form. Your Information First Name Last Name Phone # Address Address Address 2 City/Town State/Province – None –AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Sex Age Race Marital Status Preferred Hospital Emergency Contacts First Emergency Contact Name Phone # Cell # Second Emergency Contact Name Phone # Cell # Physician Information Name Phone # Fax # Address Address City/Town State/Province – None –AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Standing Orders Please check the box either approving or declining action. Tylenol 350mg 1 or 2 tablets every 4 hours as needed for pain or fever – Select –YesNo Maalox 30cc every 4 hrs as needed for upset stomach – Select –YesNo Over the count cough drop every 4 hours as needed for indigestion/heartburn – Select –YesNo TUMS 1 or 2 tabs every 4 hours as needed for indigestion/heartburn – Select –YesNo Ibuprofen 200mg 1 or 2 tablets every 4 hrs as need for pain or fever – Select –YesNo Blood Sugar finger stick test as needed for signs/symptoms of hyper/hypo-glycemia – Select –YesNo Are you diabetic? – Select –YesNo Minor wound care as needed—cleanse with soap & water, apply antibiotic and dressing – Select –YesNo Medical Emergency Information Food Allergies Medication Allergies Medical Diagnosis History Medication / Dosage / Instructions Please list all your medications, dosage and instructions. What is your main reason for wanting to attend the Gilcrest Center? Who lives in your house? Do you have any pets? What are your favorite foods? What foods do you not like? What activities do you enjoy? Do you use any adaptive equipment? If so, please list. Wheelchairs, walkers, etc. Signature Disclaimer text goes here… I authorize….. Authorization Reset Sign above. Date Submit