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Notice of Non-discrimination
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Who Was John Clarke?
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Application for Apartment
Nursing Center Application
AHCA Information for Residents/Families
RI Health Care Association
American Baptist Home
US News Report on Senior Care
RI Dept of Health Nursing Home Info
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Ways to Give
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Qualified Charitable Distributions
600 Valley Road, Middletown RI 02842
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(401) 846-0743
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Home
About John Clarke
Performance and Survey Results
Medicare ⭐⭐⭐⭐⭐ Rating
Dept. of Health Survey Results
Resident and Family Satisfaction Survey Results
Meet our Staff
Our Management Team
Whatever it Takes Recognition
Board of Directors
Diversity Equity and Inclusion Statement
Notice of Non-discrimination
History of John Clarke
Who Was John Clarke?
Living Options
Senior Living Apartments
Nursing Center
Life At John Clarke
Chaplain’s Services
Image Gallery
Our Newsletter
Resources
Application for Apartment
Nursing Center Application
AHCA Information for Residents/Families
RI Health Care Association
American Baptist Home
US News Report on Senior Care
RI Dept of Health Nursing Home Info
Residents Only
DONATE
Ways to Give
Donor Advised Funds
In Your Will
Giving from your IRA
Qualified Charitable Distributions
John Clarke Nursing Center Application
600 Valley Road, Middletown, RI 02840
Phone: 401-846-0743 Fax: (401) 848-5890
Please enable JavaScript in your browser to complete this form.
Date of Application:
*
Email
*
Name of person assisting with application/ relationship:
Name
*
First
Last
Phone Number:
*
Reason for admission:
*
Address:
*
Applicants Current Location (Hospital, home, etc.)
*
Date of Birth
*
Gender:
*
Height/Weight
US Citizen
Yes
NO
Birthplace:
Primary Language:
Religion:
Lifetime Occupation:
Marital Status
Single
Married
Partnered
Divorced
Widowed
Seperated
Applicant is Seeking
Long Term placement
Short term placement
When are you looking for placement:
Current Home Care Agencies Involved: (if any)
Physician's Name:
Physician's Phone:
Single Line Text
Assistance with Walking
Independent
Needs Assistance
Unable / Non-Weight Bearing
Comments for Walking:
Assistance with Eating:
Independent
Needs Assist
Unable
Comments for Eating:
Personal Care:
Independent
Needs Assist
Unable
Comments for Personal Care:
Dressing:
Independent
Needs Assist
Unable
Comments for Dressing:
Bathing
Independent
Needs Assist
Unable
Comments for Bathing
Bathroom
Independent
Needs Assist
Unable
Comments for Bathroom
Continent of Bladder:
Yes
No
Sometimes
Continent of Bowel:
Yes
No
Sometimes
Alcohol Use:
Yes
No
Does the applicant smoke? (JC is a smoke free facility)
Yes
No
Please describe applicant’s usual sleeping pattern:
Please describe applicant’s current ability to recall short term and long term
Applicant’s food preferences:
Will the applicant’s physician be following them in this facility?
Yes
No
If yes, physician's name/ phone:
Please describe applicant’s current medical condition, and most recent hospitalizations
Please list all allergies:
Does the applicant use the following?
Partials/ Dentures
Cane
Walker
Wheelchair
Oxygen
Special Utensils
Emergency Contacts (please list all names, relationship and phone numbers)
Social Security #
*
Medicare #
Medicaid #
Are you a Veteran?
Yes
No
Home Decisions Gender:
Blue Cross / Blue Shield #
Other Insurance Name and #
Power of Attorney for Health Care Decisions
Yes
No
If yes, please provide name, number and relationship to applicant
Power of Attorney for Financial Decisions
Yes
No
If yes, please provide name, number and relationship to applicant
Does Applicant have living will?
Yes
No
Signature / Date (applicant or responsible party)
Submit
