Resident Personal Data Sheet - Confidential and Proprietary

Assisted Living Company Name:

Section 1: Resident Information

1. Full Name:

2. Date of Birth: Month1 January2 February3 March4 April5 May6 June7 July8 August9 September10 October11 November12 DecemberDay12345678910111213141516171819202122232425262728293031Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035 Age: Years

3. Gender: ===== MaleFemaleOtherPrefer not to say

4. Social Security Number (SSN):

5. Medicare/Medicaid Number:

6. Marital Status: ===== SingleMarriedWidowedDivorcedOther

7. Preferred Language:

8. Religion/Spiritual Preferences:

Section 2: Contact Information

1. Primary Address (if applicable):

2. Phone Number: Email:

3. Emergency Contact Name:
   Relationship: Phone:

4. Secondary Emergency Contact Name:
   Relationship: Phone:

Section 3: Medical Information

1. Primary Physician Name:
   Phone: Address:

2. Medical Conditions/Diagnoses:

   ---

3. Allergies (Food, Medication, Environmental):

   ---

4. Current Medications:

   • Medication: Dosage: Frequency:

   • Medication: Dosage: Frequency:

   • Medication: Dosage: Frequency:
   • Medication: Dosage: Frequency:

5. Special Medical Needs (e.g., oxygen, wheelchair, etc.):

   ---

6. Advance Directives/Living Will: YesNo Location:

Section 4: Personal Preferences

1. Dietary Preferences/Restrictions:
   
   

2. Daily Routine Preferences:

   ---

3. Hobbies/Interests:

   ---

4. Preferred Activities:

   ---

5. Cultural or Religious Practices:

   ---

Section 5: Financial and Legal Information

1. Power of Attorney (POA) Name:
   Phone:  Email:
2. Guardian/Conservator Name (if applicable):
   Phone:  Email:
3. Insurance Information: Provider: Policy Number:
   • Provider: Policy Number:  
   • Provider: Policy Number:  
4. Payment Method for Services: Private PayInsuranceMedicaidOther

Section 6: Additional Notes

1. Resident’s Personal Goals:

   ---

2. Family Involvement Preferences:

   ---

3. Other Important Information:

   ---

Section 7: Consent and Authorization

1. I authorize [Your Assisted Living Company Name] to use this information to provide care and services.
   Resident Signature:

   *
   
   Date: Day12345678910111213141516171819202122232425262728293031Month1 January2 February3 March4 April5 May6 June7 July8 August9 September10 October11 November12 DecemberYear1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035

2. I authorize the sharing of this information with relevant healthcare providers.
   Resident Signature:

   *
   
   Date: Day12345678910111213141516171819202122232425262728293031Month1 January2 February3 March4 April5 May6 June7 July8 August9 September10 October11 November12 DecemberYear1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035

[Your Assisted Living Company Name]
Phone: Email:

E-Sign Act Disclosure and Agreement

Your Consent To Use Electronic Records and Electronic Signatures

This website has elected to use electronic signatures as the default choice in lieu of paper. Be advised that according to the U.S. Federal E-SIGN Act in addition to various state laws an electronic signature is legally the same as a paper and ink signature. Also be advised in event enforcement is needed, all signatures are held in trust by SwiftSignature.com, as a neutral 3rd party, and may be legally enforced in court of law as per the terms of your respective contract.

Federal law requires certain safeguards to ensure that both consumers and vendors have the capability to receive copies of documents upon signature and are advised of the consequences of agreeing to receive documents electronically. Federal law also requires your consent to use e-mail and electronic versions of said contract and/or agreements, disclosures, and other documents and records, herein referred to as simply "electronic documents" that would otherwise be legally binding only if provided to you on paper as a printed physical document.

Electronic Documents for purpose of this disclosure include any documents signed using the Swift Signature service. All documents once signed cannot be revoked or canceled and will be stored for a minimum period of ten (10) years, and are available to either party at any time through our electronic web portal.

Free Document Storage Account

All signors are automatically entitled to a free document storage account within Swift Signature, the cost of which is given to you by the owner of this website. After signature, you may follow the prompts to save your document to your free account, where it will be accessible for a minumum of 10 years. This account is optional and available as a courtesy to you.

Right to withdraw consent

Note you do have the right to withdraw your consent to receive and/or use electronic documents, but be advised this does not cancel or revoke any prior documents for which permission existed at that time. The legal validity and enforcement of electronic documents, signatures, and deliveries used prior to revocation of consent will not be affected. To withdraw your consent, please contact the owner of this website.

Right to receive paper document

You have the right to have any document in paper form, should you choose at no charge to you. To request paper documents, please contact the party who referred you to this service.

By clicking "Sign and Send" on any document posting to SwiftCloud servers, you are agreeing to the terms contained herein, and are providing your consent to the use of electronic documents and signatures, as well as e-mail or sms phone message delivery of related electronic documents. You are also acknowledging receipt of this disclosure.

Hardware & Software Requirements

Use of this Service Requirements

1. Connection to the internet
2. Any internet web browser with graphical interface and a pointing device, aka "a mouse" for desktop computers or a touch screen for tablets or modern phones common after 2004
3. a PDF reader or browser capable of displaying Adobe PDF documents
4. A printer, should you wish to print and retain a paper copy of signed documents.

Acknowledgement of your access and consent to electronic records and electronic signature

By clicking "Sign & Send" on any document posting to this service, you agree that

• You were able to read this E-SIGN Act Disclosure & Agreement
• Should you desire, you were able to print on paper or electronically save this agreement for future reference
• You have an active email on file with the owner of this website
• That the device on which you indicated your agreement or signature, including both your hardware and your software comply with the terms above and were able to render the agreement in a fashion functionally equivalent to paper, and that the document agreed to was both readable and understandable.
• That any indication of signature and/or initials in addition to information provided is wholly yours and subject to the terms above.
• You consent to receive electronically any records, notices, agreements or disclosures made to you by our client, the referring service, during the course of your relationship with that company, subject to revocation per terms above.

Electronic Signature         Disclosure & Consent

Document Blockchain ID: cCI3Amjt2K3OgZc3WGQLIgkvvimegDIFKsEOLO0rNNs1wfElMQp8aJbRkmS0n13y, Signed on: , Signer 1 given identity: user@gmail.com, email verified by signer, IP Address: , Via browser: , Running on: , Language: , Timezone: , Resolution: , Destruction Date: , Document last modified prior to signature: