Schedule an In-Person Visit

Resident's Name*

First Last

Your Name*

First Last

Your Email*

Preferred Day for Visit

Preferred Time for Visit (9am to 5pm only)

: HH

MM

Have you been exposed to anyone under evaluation for exposure to Covid-19?*

Yes
No

Have you been around anyone that has been sick in the last 7 days?*

Yes
No

Have you been vaccinated for Covid-19?*

Yes
No

Did you receive both doses if using a multi-dose vaccine?*

Yes
No

When was the date of your last vaccination?

Do you currently or in the previous 72 hours have had any of the following symptoms: fever, cough, shortness of breath, headache, body aches, sore throat, diarrhea or nausea/vomiting?*

Yes
No

I understand that I need to wait until my appointment has been confirmed by a staff member before I go to the facility.*

Yes
No

If you are bringing in any clothing or belongings for your loved one, please list them here and ensure they are labeled with their name.

Policy Acknowledgement - Bringing In Food For A Resident*

I agree to the food policy.

If you plan to bring food into the facility for a resident, please be sure to follow these food safety suggestions. - Food or beverages should be labeled and dated to monitor for food safety. - Food or beverages may be in the original containers marked with manufacturer expiration dates and unopened. - Raw eggs or dishes made with raw eggs for consumption (i.e. eggnog, poached eggs) are not permitted. - Foods or beverages that are past the manufacturer’s expiration date will be thrown away. - Any suspicious or obviously contaminated food or beverages will be thrown away immediately. - No food will be shared with other residents or staff unless approved by a nurse - Prepared foods, beverages, or perishable foods must be consumed within two hours. The facility will not store, refrigerate or reheat food brought from the outside. - Patient snacks will be subject to a shoe-box-sized storage limit to avoid trip hazards and clutter in resident rooms. Snacks in boxes beyond this storage limit will be refused. - Any delivered food from outside food vendors, restaurants, etc. must be consumed within two hours of arrival to the facility. - Any foods requiring refrigeration or freezing for storage will be refused or thrown away. PROHIBITED ITEMS LIST This list is not all-inclusive and any items deemed unsafe, unpleasant, or disruptive to patient care will be removed by facility administration. - Items of expensive value (greater than $100.00 USD in value) should not be brought into the facility and if they are brought in, they are done so at the residents’ express risk of loss and will not be covered under the facility’s theft and loss policy. - Cash should not be brought in or stored in the resident room, the Business Office Manager can assist with cash storage and trust fund management. - Cigarettes, lighters, flame-making material, cigarette-making material cannot be stored by a resident and must be turned into the nursing staff for safe storage. Any items found in a resident room of this nature will be confiscated. - Weapons of any kind, knives of any kind. - Marijuana and materials of any kind or substance. - Alcoholic beverages. - Self-defense devices of any kind including pepper spray. - Glass containers. - Furniture, cots, etc. - Any suspicious items may be subject to search, inspection, and removal by facility personnel.

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