Application for Admission | Heritage Place Assisted Living and Wellness Center

Heritage Place Assisted Living
Application for Admission

(If applying with a co-applicant, please compete this form for each party)

Date of Application
Resident Information
First Name	Last Name
Address
City	State	Zip Code
Date of Birth	Social Security Number
Marital Status Single Married Widowed Divorced		Gender Male Female
Physician
Current Health Problems
Medications
Special Needs
Apartment Preference
Requested Move-in Date
Note: A deposit of $750 must be included with the application. The deposit is refundable if for any reason you do not move in. A pre-admission interview is required prior to acceptance for occupancy. If you submit your application online, you will need to contact us at Heritage Place immediately to make payment arrangements for your deposit.
Return to: Heritage Place Assisted Living 1000 6th Avenue West Bandon, OR 97411

Thank you!

Heritage Place
Admission Checklist

In order to make the process as smooth as possible, the following items should be completed or arranged prior to move in:

Signed Rental Agreement
Move-in fee and first month's rent paid
Individualized assessment outlining your needs and desires
Release signed to obtain past medical history and signed physician's orders
Medications (if needed)
Newspapers (if desired)
Mail change of address:
Your Name
1000 6th Avenue West Apt #_____
Bandon, OR 97411
Phone (hookup provided) 800-483-4000 for Verizon
Cable TV (hookup provided) 866-731-5420 for Charter Cable
Dish Network 541-267-2175 for Oregon Satellite
To get telephone and cable hookup you need to give Verizon and Charter the following address in order for them to recognize Heritage Place in their system:
Your Name
1000 6th Avenue Southwest Apt #_____
Bandon, OR 97411

To give your apartment a feeling of home:
(Physical moving of furniture is resident's responsibility)