Submit an application - HEART OF PASSION

Patient's Full Name*

Patient's date of birth*

Patient's date of birth

Patient's Marital Status*

Patient's Physical Address*

Will the account be settled cash or medical aid?*

If cash please advise source of funds - else type N/A*

Medical Aid Name*

Medical Aid Plan Option*

Medical Aid Membership Number*

Please state all medical conditions the patient has been or is currently being treated for.*

Please state all surgeries that the patient has undergone.*

Special Dietary Requirements - if none please type N/A*

Doctor's Full Name*

Doctor's Phone Number*

Full Name of person responsible for the account*

Person responsible for the account relation to the patient*

E-mail of person responsible for the account*

Phone Number of person responsible for the account*

Postal Physical Address of person responsible for the account*

Full Name of emergency contact person*

Phone Number of emergency contact person*

Full Name of person with Power of Attorney*

Contact number of person with Power of Attorney*

CONDITIONS OF ADMISSION TO THE HEART OF PASSION LIVING CENTRE (herein referred to as Home)

1. A deposit and first month rent will be payable before the patient moves into the Home. Thereafter the monthly rental must be paid to the Home on the 1st of each month. The deposit will be returned when the patient leaves the Home provided that a notice period of one month is given to the Home in advance (Please Note: that a month is taken as starting from the 1st). If the patient passes on before the end of the month, the rental will still have to be paid for the full month. The deposit will be returned minus any additional expenses that were incurred by the patient prior to his\her death.

2. A 10% increase in rental will be added per year.

3. The Home does not offer a month-to-month contract for care of a patient. The minimum period of stay at the Heart of Passion Living Centre is six months. After this period of six months, a month’s notice is required if the patient needs to be moved from the Home. If the patient passes on within the six-month period, then the application is cancelled.

4. The Heart of Passion Management will not be held responsible for articles or cash not given to them for safekeeping.

5. Where there is a deterioration of the patient’s health and when care that is more appropriate becomes necessary, the applicant or sponsor must be willing to transfer the patient to a relevant Health facility. The Nursing Sister of the Home will decide on the need for such transfer. The patient\ sponsor is responsible for all costs incurred for transfer of the patient.

6. Residents who require additional care while in the Home will be charged separately for this care.

7. The patient or sponsor will meet Doctor’s bills, medication, nappies if required by the patient and cost of transport to see doctor or collect medication.

8. A weekend pass out for the patient will require a week’s prior notice and discussion with Management. The pass out will only be given to the responsible sponsor and Management should be notified early if for some reason, the patient is unable to return to the Home as arranged.

9. Visitors will be allowed to visit the patient during visiting hours only, unless there is an emergency.

10. With due consideration given to the safety of the patients, no traditional lamps\candles should be brought to the Home.