Welcome to Buckingham Pavilion – The award winning personal care residence.

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773-973-5333
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Residency Application

Step 1 of 8

12%

General Information
Name*
Home Phone #
Cell #
Email
Current Address
Name of person you are inquiring for:
First Last
Sex
- Male
- Female
Date of Birth
MM slash DD slash YYYY
Place of Birth (City)
Place of Birth (State)
Place of Birth (Country)
Marital Status
- Single
- Married
- Divorced
- Widow
Name of Spouse

Insurance Information
Medicare Number
Do you have Supplemental Medical Insurance?
Name of Company
Policy #
Group #
HMO Insurance Provider
Policy#
Long Term Care insurance
Policy #
Phone Number
Contact
Medicaid Number
Medicare Part D
Please attach a copy of the card for all policies listed above
Drop files here or

Accepted file types: jpg, pdf, docx, rtf, txt, Max. file size: 10 MB, Max. files: 5.

Are you applying for LONG TERM OR SHORT TERM CARE?
- Long Term (90 Days or More)
- Short Term (90 Days or Less)
Admission Date desired at Buckingham Pavilion:
MM slash DD slash YYYY
Applicant's current living situation
- Alone at home
- At home with Caregiver
- Assisted Living
- Nursing Home
- Retirement Community
- Other (Please Mention)
Other (Please Mention)

Income Information
Assets
Own a home
Approximate Value $
Checking Account $
Savings Account $
Other
Income Type
Average Monthly Income
Amount
Income Type
Amount
Income Type
Amount
Income Type
Does the applicant intend to file for Public Aid/Medicaid in the next 2 months

Medical Tests
Please attach a copy of the proof of items listed below if available
- Vaccination status
- Flu
- Pneumococcal
- Tetanus
- COVID (Include dates and type)
- DNR
- POA
Attach Files
Drop files here or

Accepted file types: jpg, pdf, docx, rtf, txt, Max. file size: 512 MB.

Medical Information
Diagnosis
Reason for placement
Primary Physician
Name
Phone
Address
Other Doctors
Name
Phone
Address
Name
Phone
Address

Likes or Dislikes
Any Important information you would like to share:
Monthly Cost
The charge per day for semi private is $ 365. The Charge per day for a private room is $ 450 This Includes:
- 24 hour nursing care
- 3 meals a day plus snacks
- Personal care like grooming, dressing, eating and ambulation
- Activities
- Social services
- Music, art religious programs
- Dietitian consultation
- Housekeeping towels and linen service.
Agreement
All of the above information is correct and true to my best knowledge, I hereby authorize owner's agent to verify above information and authorize all individuals that I know and all creditors and credit agencies to release all information which may be requested in connection with this application. If any of the above information is not accurate or complete Buckingham Pavilion will have the right, if it chooses to either deny admission or discharge the patient.
Signature of Applicant

2625 West Touhy Avenue
Chicago, Illinois 60645

Phone: 773-973-5333
Fax: 773-973-5222
Email: info@buckinghampavilion.com

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Email*

info@buckinghampavilion.com

© 2024 Buckingham Pavilion, All Rights Reserved.

Step 1 of 25

4%

I am taking this Care Questionnaire for:*
- Myself
- My Parents
- My Spouse
- A Patient
- Someone Else

Are you experiencing any of the following?
- Trouble Hearing / Hearing loss
- Low Vision / Difficulty Seeing
- Difficulty Walking
- Difficulty Eating
- Depression
- Falling
Check all that apply or if none click next.

Have you stayed in any of the following in the last 6 months?
- Hospital
- Rehab/Skilled Nursing Facility
- Assisted Living Facility
- In-Patient Stay
Check all that apply or if none click next.

Do you need someone to help you with any of the following?
- Getting Dressed
- Bathing
- Using the bathroom
- Preparing Meals
- Taking Medications
Check all that apply or if none click next.

Do you have difficulty remembering things such as paying your bills each month?*
- Yes
- No

Have you ever been diagnosed with dementia or Alzheimer's?*
- Yes
- No

Have you ever wandered or driven away from a known location and felt disoriented or lost?*
- Yes
- No

Do you have additional information to share? (Optional):
Name*
Email*
Phone*
Results
- Get Results
Results
- Get Results
Results
- Get Results

Does your loved one require in-home support 24 hours a day?*
- Yes
- No

Is your loved one experiencing any of the following?
- Trouble Hearing / Hearing loss
- Low Vision / Difficulty Seeing
- Difficulty Walking
- Difficulty Eating
- Depression
- Falling
Check all that apply or if none click next.

Has your loved one stayed in any of the following in the last 6 months?
- Hospital
- Rehab/Skilled Nursing Facility
- Assisted Living Facility
- In-Patient Stay
Check all that apply or if none click next.

Does your loved one need someone to help them with any of the following?
- Getting Dressed
- Bathing
- Using the bathroom
- Preparing Meals
- Taking Medications
Check all that apply or if none click next.

Is your loved one having difficulty remembering things such as paying their bills each month?*
- Yes
- No

Is your loved one ever been diagnosed with dementia or Alzheimer's?*
- Yes
- No

Has your loved one ever wandered or driven away from a known location and felt disoriented or lost?*
- Yes
- No

Do you have additional information to share? (Optional):
Name*
Email*
Phone*
Results
- Get Results
Results
- Get Results
Results
- Get Results

Do they require in-home support 24 hours a day?*
- Yes
- No

Are they experiencing any of the following?
- Trouble Hearing / Hearing loss
- Low Vision / Difficulty Seeing
- Difficulty Walking
- Difficulty Eating
- Depression
- Falling
Check all that apply or if none click next.

Have they stayed in any of the following in the last 6 months?
- Hospital
- Rehab/Skilled Nursing Facility
- Assisted Living Facility
- In-Patient Stay
Check all that apply or if none click next.

Do they need someone to help them with any of the following?
- Getting Dressed
- Bathing
- Using the bathroom
- Preparing Meals
- Taking Medications
Check all that apply or if none click next.

Do they have difficulty remembering things such as paying their bills each month?*
- Yes
- No

Have they ever been diagnosed with dementia or Alzheimer's?*
- Yes
- No

Have they ever wandered or driven away from a known location and felt disoriented or lost?*
- Yes
- No

Do you have additional information to share? (Optional):
Name*
Email*
Phone*
Results
- Get Results
Results
- Get Results
Results
- Get Results

Result

You may need memory care

WhatsApp Image 2022-04-26 at 2.30.38 PM

WhatsApp Image 2022-04-26 at 2.30.39 PM (1)

WhatsApp Image 2022-04-26 at 2.30.39 PM

WhatsApp Image 2022-04-26 at 2.30.38 PM (2)

WhatsApp Image 2022-04-26 at 2.30.38 PM (1)

*This is not an assessment by a licensed professional and should not be taken as a diagnosis by a physician. You will need to speak to a All Seasons Senior Living representative to validate the results of this questionnaire.
When you speak to a All Seasons Senior Living representative it will be determined if we can meet your care needs. If it is determined we can, then the level of care will be selected. The results of the assessment are owned by All Seasons Senior Living and should not be considered a health care diagnosis/evaluation.

Schedule a Tour

Name*
Email*
Phone*
What services are you interested in?*
- Assisted Living Plus
- Memory Care
- Skilled Nursing
- Rehabilitation & Transitional Care
- Parkinson's Care
- Long Term Care
You are interested in Buckingham Pavilion for:*
- Yourself
- A Family Member
- A Friend
- A Client
- Other

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