Fillable Seminole County Office of Emergency Management VOLUNTARY MEDICALLY (Seminole County Government)

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Seminole County Office of Emergency Management VOLUNTARY MEDICALLY (Seminole County Government)

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File type: PDF

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Seminole County Office of Emergency Management
VOLUNTARY MEDICALLY ENHANCED SHELTER / WELL CHECK PROGRAM REGISTRATION FORM
This form must be filled out completely. Please print clearly.
By signing up for the Voluntary Medically Enhanced Shelter / Well Check Program, you are acknowledging that you have read, understood, and agree with the Notice of Privacy Practices for Protected Health information.
By signing up for the Voluntary Medically Enhanced Shelter / Well Check Program, you are acknowledging that you have read, understood, and agree with the Notice of Privacy Practices for Protected Health information.
PERSONAL INFORMATION
First Name:
M.I.:
Last Name:
Suffix:
CONTACT INFORMATION
Home Phone:
Cell Phone:
Caretaker Phone (if applicable):
Email Address:
HOME ADDRESS
Street Address:
City:
REGISTRATION INFORMATION
Date of Birth:
____ / ____ / __________
Sex:
M F
Type of Residence:
Single Family Home Apartment / Condo Mobile/Manufactured Home
Living Status:
Alone With Spouse / Relative With Caregiver Other (Please Specify): ______________________________
Will you have a Caretaker with you at the shelter?
Yes No
Do you use Oxygen?
Yes ( Intermittent Continuous) No
Do you use medical equipment that requires electricity to operate?
Yes ( Intermittent Continuous) No
If Yes, please specify the equipment that requires electricity:
Do you use medication that requires refrigeration?
Yes No
Do you use an LVAD (Left Ventricular Assistance Device)?
Yes No
Do you receive Dialysis?
Yes ( At Home At Facility) No
Are you confined to a bed?
Yes ( Hoyer Lift Required) No
Do you utilize a service animal?
Yes No
Do you have pets at home?
Yes No
Do you require transportation to a shelter?
Yes ( With Wheelchair Lift) No
Do you use a wheelchair?
Yes ( Electric Manual) No
OFFICIAL USE ONLY – DO NOT FILL OUT
 SpNS Shelter Well Check
Beyond Care
Reviewer Signature: Date:
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Seminole County Office of Emergency Management VOLUNTARY MEDICALLY (Seminole County Government)

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Completed 18 July 2020

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