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MX 664 799 6672

US 619 343 9762

Office Hours 9:00 am to 5:00 pm

[email protected]

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Patient Application

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Day

NAME

relationship to the patient

Email address

Phone

Month

Year

Can the patient eat by him/herself?

Can the patient speak?

Does the patient have a special diet?

What is the patient's weight?

Can the patient walk by him/herself?

Does the patient use adult diapers?

Do you desire a private or shared room?

Which language does he/she speak?

Does the patient have a chronic condition?

Is the patient in bed most of the time?

What is your monthly budget limit?

has a chronic or degenerative disease?

patient’s memory leve 1-10 scale

Does the patient need hospice care?

Contact Information

Patient Information

Date of birth

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ABOUT US

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US 619 343 9762

[email protected]

Office Hour 9:00 am to 5:00 pm

Tulipanes 9566, Jardines de La mesa, 22126 Tijuana BC

SENIOR CARE IN BAJA

Formed by interdisciplinary specialists, dedicated to ensure the safety and well-being of our elders through our residencies.

patient application

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