Southern Harbor House
APPLICATION AND PRE-ADMISSION FORM

Applicant's Name *
Applicant's Name
Date of Birth *
Date of Birth
Sex *
Marital Status *
Address *
Address
Ambulatory *
Lived Alone? *
If admitted from home, date of most recent hospitalization
If admitted from home, date of most recent hospitalization
Primary Contact
Primary Contact Name
Primary Contact Name
Primary Contact Address *
Primary Contact Address
Secondary Contact
Secondary Contact Name *
Secondary Contact Name
Secondary Contact Address *
Secondary Contact Address
Additional Contact
Additional Contact Name
Additional Contact Name
Additional Contact Address
Additional Contact Address
Advanced Directives
For application to be valid, each checked item must include a copy of the corresponding document sent to Southern Harbor Eldercare Services Fax: 207.863.5027 US Mail: 12 Pulpit Harbor Road, North Haven, Maine 04853
Advanced Directives *
Financial Arrangements *
If NO, invoices will be sent directly to you. If YES, to whom would bill be directed. Indicate in address field below.
Financial Arrangement Billing Address
Financial Arrangement Billing Address
$
$
$
Maine Care Applied for *
Maine Care Applied for
Exact date or estimate.
Bank Statements
Copies of all checking and savings account statements for the past three months must be sent to Southern Harbor Eldercare Services: For application to be valid, each checked item must include a copy of the corresponding document sent to Southern Harbor Eldercare Services Fax: 207.863.5027 US Mail: 12 Pulpit Harbor Road, North Haven, Maine 04853