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459 East Oak Orchard St Medina, NY 14103
585.798.5233
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If not, where is your citizenship?
Marital Status
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Name of Spouse (even if deceased)
Date of Spouse’s Birth
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What has been your occupation?
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How long since you were a wage earner?
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Education Level
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Were you ever in the U.S. Armed Services?
*
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If yes, which branch?
Dates of Service:
Attending Physician
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Relative Information
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Relative Information
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Address
Street Address
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Statistical Information
Medicaid
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Yes
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Effective Date
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Social Security Number
Medicare Number
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Funeral Home
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Do you have a burial lot?
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Cemetery
Lot #
Social Information
Current Living Arrangements
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With Spouse
Alone
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Other
Do you prepare your own meals and manage your own person without assistance?
Do You..?
Have a Special Diet
Wear Glasses
Reading Only
At All Times
Have Hearing Aids
Right Ear
Left Ear
Both Ears
Have Dentures
Upper
Lower
Only When Eating
Always Wear
Use Protective Undergarments
At All Times
Occasionally
At Bedtime
Assistive Device
Cane
Walker
Wheelchair
Does anyone provide you care besides your primary care physician?
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Office Name
Office Address
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Office Name
Office Address
Office Phone
Office Name
Office Address
Office Phone
Office Name
Office Address
Office Phone
Office Name
Office Address
Office Phone
What medications are you currently taking?
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Have you had Mental Health Care in the last five years?
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If yes, Provider’s Name:
Provider's Address
Provider's Phone
Who is filling out this application, other than yourself?
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Email
Power of Attorney
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Virginia
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Phone
Email
Health Care Proxy
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Address
Street Address
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State
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New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
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U.S. Virgin Islands
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Virginia
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Religious Affiliation
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Attended/Attending
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