Apply Online Basic Patient Information Care Type Assisted Living Long-Term Care Name Current Address City State ZIP Email Address Phone Number Marital Status Date of Birth Medical Insurance Carrier Medical Insurance Group ID# Military ID Number (if applicable) Previous Occupation Contact Information (if not applicant) Name Address City State ZIP Phone Authorized Representative or Patient Advocate same as above same as above Name Address City State ZIP Phone Relationship Additional Patient Information Religion Physician Funeral Home Physician's Phone Physician's Address Current Medical Conditions Is assistance required in daily living? (ex. washing, grooming, etc.) Is a special diet required? (ex. low salt, diabetic, etc.) King's Daughters & Sons Circle Member? Yes No 30 year member 30 year member If you are human, leave this field blank.