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Admission Application

Select an option:
Prefix Preference:
Status:
Sex:
U.S. Citizen:
U.S. Veteran:
Spouse of Veteran:
Education:
Religion:
Pharmacy:

*If your doctor authorizes that you may administer your own medications, you may get them from whomever you please. If you need staff administration, we require you use unit dose which is available from Hartig Drug and Mercy Family Pharmacy only. 

Hospital Preference:

(A copy of each of the above cards, as well as your medical insurance card is required as part of the application process.)

Legal Status:
Legal Status:

Condition of Health: A completed personal health history form must be completed at time of application. This can be found on the "Apply for Residency" page. 

A current (within three months of admission) medical examination by a licensed physician is required prior to entering Bethany Home. The pre-admission health form must be filled out by your attending physician.

All personal items that are brought into Bethany Home must be marked with your name in an inconspicuous but readable manner, such as the marking is visible after such items have been laundered (if applicable). Clothing name tags may be ordered through Bethany Home. Hearing aids, dentures, partial plates, eye glasses, etc., must also be marked. 

According to the best knowledge and belief, the foregoing information is complete, accurate and true in all respects. I understand that the accuracy of the above financial report is one of the conditions of my acceptance at Bethany Home, and that the total resources listed on my application are available as needed for my personal care at Bethany Home. 

Thanks for submitting!

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