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Hilton East Reservation Form (Printable Version)

Hilton East Assisted Living Community has been locally owned and operated for over 40 years, allowing us to adjust to changing needs for our residents.

Let us Help you Find the Perfect Solution!

Contact Us to Learn More!

CONTACT US

Hilton East Assisted Living Community
231 East Avenue
Hilton, NY 14468
P: 585-392-7171
E: info@hiltoneast.com

OUR MISSION

To provide quality personalized care in an environment that fosters caring independence.

Home
About Us
Life at Hilton East
Rooms & Rates
FAQ’s
Events
Tour Hilton East
Reservation Checklist
Reservation Form
Employment
Volunteering
Contact

CONTACT US

Hilton East Assisted Living Community
231 East Avenue
Hilton, NY 14468
P: 585-392-7171
E: info@hiltoneast.com

To provide quality personalized care in an environment that fosters caring independence.

Home
About Us
Life at Hilton East
Rooms & Rates
FAQ’s
Events
Tour Hilton East
Reservation Checklist
Reservation Form
Employment
Volunteering
Contact

Terms & Conditions | Privacy Policy
Copyright 2003 - 2021 Hilton East Assisted Living Community | Web Design & Hosting: B Square Web

Terms & Conditions | Privacy Policy

Copyright 2003 - 2021 Hilton East Assisted Living Community

Web Design & Hosting: B Square Web

If you are human, leave this field blank.

Reservation Form

Please complete the entire reservation form with the most up-to-date information as possible in order to expedite the admission process. (Please note, information requested is required by New York State for admission to a state-licensed care facility)

Full Name

Current Address

Apt, suite, etc.

Country

City

State

Zip code

Sex

Male

Female

Date of Birth

Place of Birth

Social Security Number

Religious Preference

Are you or your spouse a veteran?

Yes

No

If Yes, did you serve during war time?

Yes

No

Current Living Situation

Own Home

With Family

Nursing Home

Apartment

Hospital

Family Information

Marital Status

Single

Married

Widowed

Divorced

Spouse's Name (if applicable)

Mother's Name (including maiden name)

Father's Name

Children's Names

Other Important Relatives to Note

Health Insurance

Primary Health Insurance

Insurance #

Secondary Health Insurance

Insurance #

Medicaid #

Room Request

(call for current pricing)

When are you planning to move in?

Private Rooms (Single & Shared) with en-suite bathroom (setup fee required)

Cozy Private

Large Private

Semi-Private

Two-Room Suite (with shower)

Medicaid Rooms

Please place me on a waiting list if not currently available

I can privately pay until a room is available

Financial Information

Income

Please provide your total annual income amount including employment plus benefits for each

Social Security

Child Support

SSI

Family

SSDI

Veteran's Benefits

Employment

Other

Current Assests

Checking

Trust Fund

Savings

Real Property (Value)

Certificate of Deposit

Other (Annuity, etc.)

Liabilities

List notes, taxes, loans, credit cards, and other debts including dollar amounts.

Which benefits have you already applied for?

VA Benefits

SS Supplemental Income

Disability

Medicaid

Which benefits will you need to apply for?

VA Benefits

SS Supplemental Income

Disability

Medicaid

Financial Representative Payee

Relationship

Financial Representative Phone (Work)

Financial Representative Phone (Home)

Are you your own guardian?

Yes

No

If no, were you adjudicated incompetent by a court hearing?

Yes

No

Effective Date

Name of Legal Guardian

Relationship

Type of Guardianship

Address

Apt, suite, etc.

Country

City

State

Zip code

Home Phone

Cell Phone

Work Phone

Legal Power of Attorney

Address

Apt, suite, etc.

Country

City

State

Zip code

Home Phone

Cell Phone

Work Phone

Please list any other pertinent information relative to resident representation and/or guardianship:

Please Note:

All room and board payments are now required to be made via direct deposit EFT.

Medical Information

Do you have a DNR order?

Yes

No

Do you need oxygen?

Yes

No

Do you have any food allergies?

Yes

No

If yes, please list:

Do you have any medication allergies?

Yes

No

If yes, please list:

Do you have any other allergies?

Yes

No

If yes, please list:

Do you use a device? (i.e. a walker)

Yes

No

If yes, please list:

Do you require a special diet?

Please note - Hilton East only provides the following diets: Regular, No Concentrated Sweets, No Added Salt

Yes

No

Are you a smoker?

Yes

No

Mental Health Information

Have you ever been diagnosed with a mental illness?

Yes

No

If yes, what is your primary diagnosis?

What is your secondary diagnosis?

Do you take medication for your mental illness?

Yes

No

If yes, please list by name:

Do you take medication by yourself?

Yes

No

Medical/Physical Information

Primary Diagnosis:

Secondary Diagnosis:

Other Physical Limitations:

Do you take medications?

Yes

No

Do you take medications independently?

Yes

No

Physical Limitations?

Ambulation

Sight

Hearing

Other

Please describe any limitations you checked:

Do you need assistance with medication administration?

Yes

No

What pharmacy do you currently use?

Do you plan to keep your current primary care physician or switch to our house physician?

Keep

Switch

Current Provider Contact Information

Primary Care Physician

Date of last visit:

Phone

Address

Apt, suite, etc.

Country

City

State

Zip code

Preferred Hospital

Date of last visit:

Phone

Address

Apt, suite, etc.

Country

City

State

Zip code

Psychiatrist

Date of last visit:

Phone

Address

Apt, suite, etc.

Country

City

State

Zip code

Dentist

Date of last visit:

Phone

Address

Apt, suite, etc.

Country

City

State

Zip code

Opthalmologist

Date of last visit:

Phone

Address

Apt, suite, etc.

Country

City

State

Zip code

Podiatrist

Date of last visit:

Phone

Address

Apt, suite, etc.

Country

City

State

Zip code

Other Physician

Date of last visit:

Phone

Address

Apt, suite, etc.

Country

City

State

Zip code

Mental Health Provider

Date of last visit:

Phone

Address

Apt, suite, etc.

Country

City

State

Zip code

Undertaker

Date of last visit:

Phone

Address

Apt, suite, etc.

Country

City

State

Zip code

Burial Instructions:

Additional Contacts

Name:

Relationship:

Address

Apt, suite, etc.

Country

City

State

Zip code

Home Phone

Work Phone

Email

Name:

Relationship:

Address

Apt, suite, etc.

Country

City

State

Zip code

Home Phone

Work Phone

Email

Name:

Relationship:

Address

Apt, suite, etc.

Country

City

State

Zip code

Home Phone

Work Phone

Email

All of the information provided in this reservation form is accurate and truthful to the best of my knowledge.

Resident Name:

Signature

Reset Signature

Date

Home
About Us
Life at Hilton East
Rooms & Rates
FAQ’s
Events
Tour Hilton East
Reservation Checklist
Reservation Form
Employment
Volunteering
Contact

If you are human, leave this field blank.

Reservation Form

Please complete the entire reservation form with the most up-to-date information as possible in order to expedite the admission process. (Please note, information requested is required by New York State for admission to a state-licensed care facility)

Full Name

Current Address

Apt, suite, etc.

Country

City

State

Zip code

Sex

Male

Female

Date of Birth

Place of Birth

Social Security Number

Religious Preference

Are you or your spouse a veteran?

Yes

No

If Yes, did you serve during war time?

Yes

No

Current Living Situation

Own Home

With Family

Nursing Home

Apartment

Hospital

Family Information

Marital Status

Single

Married

Widowed

Divorced

Spouse's Name (if applicable)

Mother's Name (including maiden name)

Father's Name

Children's Names

Other Important Relatives to Note

Health Insurance

Primary Health Insurance

Insurance #

Secondary Health Insurance

Insurance #

Medicaid #

Room Request

(call for current pricing)

When are you planning to move in?

Private Rooms (Single & Shared) with en-suite bathroom (setup fee required)

Cozy Private

Large Private

Semi-Private

Two-Room Suite (with shower)

Medicaid Rooms

Please place me on a waiting list if not currently available

I can privately pay until a room is available

Financial Information

Income

Please provide your total annual income amount including employment plus benefits for each

Social Security

Child Support

SSI

Family

SSDI

Veteran's Benefits

Employment

Other

Current Assests

Checking

Trust Fund

Savings

Real Property (Value)

Certificate of Deposit

Other (Annuity, etc.)

Liabilities

List notes, taxes, loans, credit cards, and other debts including dollar amounts.

Which benefits have you already applied for?

VA Benefits

SS Supplemental Income

Disability

Medicaid

Which benefits will you need to apply for?

VA Benefits

SS Supplemental Income

Disability

Medicaid

Financial Representative Payee

Relationship

Financial Representative Phone (Work)

Financial Representative Phone (Home)

Are you your own guardian?

Yes

No

If no, were you adjudicated incompetent by a court hearing?

Yes

No

Effective Date

Name of Legal Guardian

Relationship

Type of Guardianship

Address

Apt, suite, etc.

Country

City

State

Zip code

Home Phone

Cell Phone

Work Phone

Legal Power of Attorney

Address

Apt, suite, etc.

Country

City

State

Zip code

Home Phone

Cell Phone

Work Phone

Please list any other pertinent information relative to resident representation and/or guardianship:

Please Note:

All room and board payments are now required to be made via direct deposit EFT.

Medical Information

Do you have a DNR order?

Yes

No

Do you need oxygen?

Yes

No

Do you have any food allergies?

Yes

No

If yes, please list:

Do you have any medication allergies?

Yes

No

If yes, please list:

Do you have any other allergies?

Yes

No

If yes, please list:

Do you use a device? (i.e. a walker)

Yes

No

If yes, please list:

Do you require a special diet?

Please note - Hilton East only provides the following diets: Regular, No Concentrated Sweets, No Added Salt

Yes

No

Are you a smoker?

Yes

No

Mental Health Information

Have you ever been diagnosed with a mental illness?

Yes

No

If yes, what is your primary diagnosis?

What is your secondary diagnosis?

Do you take medication for your mental illness?

Yes

No

If yes, please list by name:

Do you take medication by yourself?

Yes

No

Medical/Physical Information

Primary Diagnosis:

Secondary Diagnosis:

Other Physical Limitations:

Do you take medications?

Yes

No

Do you take medications independently?

Yes

No

Physical Limitations?

Ambulation

Sight

Hearing

Other

Please describe any limitations you checked:

Do you need assistance with medication administration?

Yes

No

What pharmacy do you currently use?

Do you plan to keep your current primary care physician or switch to our house physician?

Keep

Switch

Current Provider Contact Information

Primary Care Physician

Date of last visit:

Phone

Address

Apt, suite, etc.

Country

City

State

Zip code

Preferred Hospital

Date of last visit:

Phone

Address

Apt, suite, etc.

Country

City

State

Zip code

Psychiatrist

Date of last visit:

Phone

Address

Apt, suite, etc.

Country

City

State

Zip code

Dentist

Date of last visit:

Phone

Address

Apt, suite, etc.

Country

City

State

Zip code

Opthalmologist

Date of last visit:

Phone

Address

Apt, suite, etc.

Country

City

State

Zip code

Podiatrist

Date of last visit:

Phone

Address

Apt, suite, etc.

Country

City

State

Zip code

Other Physician

Date of last visit:

Phone

Address

Apt, suite, etc.

Country

City

State

Zip code

Mental Health Provider

Date of last visit:

Phone

Address

Apt, suite, etc.

Country

City

State

Zip code

Undertaker

Date of last visit:

Phone

Address

Apt, suite, etc.

Country

City

State

Zip code

Burial Instructions:

Additional Contacts

Name:

Relationship:

Address

Apt, suite, etc.

Country

City

State

Zip code

Home Phone

Work Phone

Email

Name:

Relationship:

Address

Apt, suite, etc.

Country

City

State

Zip code

Home Phone

Work Phone

Email

Name:

Relationship:

Address

Apt, suite, etc.

Country

City

State

Zip code

Home Phone

Work Phone

Email

All of the information provided in this reservation form is accurate and truthful to the best of my knowledge.

Resident Name:

Signature

Reset Signature

Date