Download APPLICANT`S FULL NAME: Date of Birth: Phone Number: Address

PRE-ADMISSION FORM FOR PRIVATE RESIDENCY SERVICES
APPLICANT'S FULL NAME:
NIF:
Date of Birth:
Phone Number:
Address:
Email:
Contact person:
NIF:
Relationship:
Phone Number:
Address:
Principal Diagnosis:
Estimated length of stay:
Reason:
 Family Relief (please specify):
 Post-surgery recovery:
 Other (please specify):
Requested services:
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Full board (accommodation, breakfast, lunch and dinner)
Accommodation and breakfast
Half board (accommodation, breakfast and lunch OR dinner)
Specialized Integral Rehabilitation (Physiotherapy, Occupational Therapy, Rehabilitation
Physician)
 Workshops (IT, Plastic Arts, Audiovisuals, Radio...)
Madrid, on [Month] [Day], [Year]
Signature.: ___________________
DOCUMENTATION REQUIRED
Please attach the copy of the following documents to this form:
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NIF or Passport.
Healthcare Card (Spanish citizens) / Insurance Card or Policy.
Certificate of disability
Dependency Level Degree / Individual Care Programme.
Updated reports: psychological, social, medical
Camino de Valderribas, 115 / 28038 Madrid
T 91 777 55 44 / M 669 879 846 / F 91 477 61 85
www.medular.org
Centro Concertado con la Consejería de Asuntos Sociales
Inscrita en el Registro de Fundaciones de Madrid en el Tomo IX, nº de Hoja Personal 108 – CIF- G81842130