Fallbrook Woods in Portland, Maine - Maine's Leading Memory-Care Community

ADMISSIONS

If you are interested in learning more, please complete the form below; or call 207-878-0788, and we will be pleased to assist you.

Applicant's Name *	Resident's Name *		Resident's Birthdate *


Address *		Phone Number *		Marital Status



What Are You Looking For *			Payment Options *
Residential care Memory impairment Respite			Privately funded Long term care insurance MaineCare (Medicaid)

Present Living Condition			Does the Resident Have
In own home Apartment Subsidized Boarding Hospital Relatives Other:			Guardianship Healthcare power of attorney Conservator Living will Manages own affairs Financial power of attorney

Emergency Contact
Name	Relationship to Resident		Address	Telephone


Family Members
Name	Relationship to Resident		Address	Telephone




Primary Physician
Name		Address		Telephone


Other Physician
Name		Address		Telephone


Dentist
Name		Address		Telephone



Health Devices
Glasses Hearing aid	Dentures Cane	Walker Wheelchair	Other


Religion, Place of Worship


How Did You Hear About Fallbrook Woods *