Florida Living is a Christian retirement community offering a residential oasis in the midst of aging.
Name
Cell
Emergency Contact #1
Relationship
Telephone
Address
Emergency Contact #2
Date of Birth
SS#
Vehicle Make and Model
License Plate
Local Primary Physician
Primary Physician Phone
Primary Physician Address [textarea physician_address placeholder "Address" rows:3]
Does someone serve as your Power of Attorney? YesNo
If yes, name and contact info:
Does someone serve as your Health Care Surrogate? YesNo
Do you have a Living Will and/or DNR order? YesNo
If yes, where is the original copy held? Please also provide a copy for your records here at FLRC.
Does someone serve as your Legal Guardian? YesNo
Are your final arrangements made? YesNo
Admission to FLRC may be conditional upon a physician certifying the applicant to be physically and mentally capable of living independently.
Your Email Address (required for confirmation)
