Foursquare Healthcare — Pre-Admission Intake Form

Welcome to Ashton Medical Lodge

Thank you for choosing Foursquare Healthcare for your loved one's care. Please complete this form before the scheduled admission. Your information is encrypted and protected under HIPAA regulations.

⏲ About 10 minutes

🔒 HIPAA Secure

💾 Auto-saves progress

📱 Mobile friendly

Resident Information

Basic demographics for the incoming resident

💡 Please enter the resident's legal name as it appears on their government-issued ID.

First Name *

Last Name *

Middle Name

Preferred Name

Suffix

Date of Birth *

Gender

SSN (Last 4) *

For identification only — encrypted

Primary Language *

Marital Status

Race / Ethnicity

Religion / Faith

Emergency Contact & Legal

Who should we contact and who has decision-making authority?

💡 If the person completing this form is also the emergency contact, you can check the box below to auto-fill.

I am the emergency contact

Primary Emergency Contact

Full Name *

Relationship *

Phone *

Alt. Phone

Address

Legal Authority

Power of Attorney *

Healthcare Proxy / Surrogate

If someone else holds POA or proxy, provide their name and phone

Insurance Information

Primary and secondary insurance details

💡 Have the insurance card handy — you can also upload a photo of it in the Documents step.

Primary Insurance

Insurance Type *

Insurance Provider

Member ID / MBI *

For Medicare, this is the MBI on the red/white/blue card

Group Number

Policy Holder Name

Policy Holder DOB

Resident has secondary insurance

Medical History

Current conditions, medications, and recent hospitalizations

💡 It's OK if you don't have every detail — the medical team will review all records after admission. Provide what you can.

Primary Diagnosis / Reason for Admission *

Other Medical Conditions

Current Medications

Include over-the-counter medications and supplements

Known Allergies *

Allergy Reactions

Recent Hospitalization

Hospital Name *

Discharge Date *

Hospital Stay (nights) *

Medicare requires a 3-night qualifying stay for SNF coverage

Attending Physician

Special Needs or Requests

Document Uploads

Upload documents from your phone or computer

If applicable — can be provided later

📎

Additional Documents

MissingAdvance Directive, POA

Status● Optional docs missing

Consent & Agreements

Electronic Signature

By signing below, you confirm that the information provided is accurate to the best of your knowledge.

Print Name *

Relationship to Resident *

Signature *

Tap or click to sign

Your typed name will be used as your electronic signature

Welcome to Ashton Medical Lodge

Resident Information

Emergency Contact & Legal

Insurance Information

Medical History

Document Uploads

Photo ID

Insurance Card — Front

Insurance Card — Back

Hospital Discharge Summary

Advance Directive / Living Will

POA / Guardianship Documents

Additional Documents

Review & Submit

👤 Resident Information

📞 Emergency Contact

🏥 Insurance

💊 Medical History

📎 Documents

Consent to Treatment

HIPAA Privacy Notice Acknowledgment

Financial Responsibility Agreement

Form Submitted Successfully!