info@rizomacare.com
619-559-3795 USA / +52 664-726-7492 MX

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Applicant Information

Please provide basic information about the applicant.

Full Name *

Date of Birth

Gender

Male

Female

Other

Primary Language

Nationality

Contact Information

How can we reach the applicant or their representative?

Current Address

Phone Number

Email Address

Preferred Contact Method

Phone

Text

Emergency Contact

Who should we contact in case of an emergency?

Full Name

Relationship

Phone Number

Email (optional)

Medical History

Please provide information about the applicant's medical conditions.

Primary Diagnoses or Conditions

1. Mobility Status

2. Cognitive Health

3. Chronic Conditions (check all that apply)

Diabetes

Stroke History

Cancer

Hypertension

COPD

Kidney Disease

4. Special Equipment Used

Oxygen

Nebulizer

Catheter

CPAP/BiPAP

Feeding Tube

Colostomy Bag

5. Medications

Care Needs

Please provide information about the level of care needed.

Level of Assistance Required

Minimal (independent with reminders)

Moderate (needs assistance with ADLs*)

High (requires full-time supervision/care)

Has the applicant experienced any recent hospitalizations?

Yes

Does the applicant have any known behavioral issues?

Yes

Lifestyle Preferences

Please provide information about the applicant's preferences.

Preferred Room Type (if available)

Private Room

Shared Room

No Preference

Preferred Start Date

Is transportation needed?

Yes

Additional Comments or Special Considerations:

Authorization

Please confirm that the information provided is accurate.

By submitting this form, I confirm that the above information is accurate to the best of my knowledge. I understand that this is a preliminary assessment and does not guarantee admission. A full evaluation will be conducted by the RIZOMA Care team.

I agree to the terms and conditions *

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Providing compassionate and personalized senior care in Tijuana, Mexico. Our mission is to enhance the quality of life for seniors through dedicated service and genuine connections.