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60 Merrymeeting Drive, Portland, ME 04103
(207) 878-0788
[email protected]
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2024-09-26T15:16:39+00:00
If you are interested in learning more, please complete the form below;
or Call Admissions Director at
207-274-6834
. We will be pleased to assist you.
Applicant's Name
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Resident's Name
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Resident's Birthday
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Phone
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Address
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What are you looking for?
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Memory impairment
Respite
Other
Payment Options
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Privately funded
Long term care insurance
MaineCare (Medicaid)
Present Living Condition
In own home
Apartment
Subsidized
Hospital
Relatives
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Does the resident have:
Healthcare power of attorney
Financial power of attorney
Guardianship
Conservator
Living will
Manages own affairs
PRIMARY CONTACT INFORMATION
Name
Relationship
Phone
Address
PRIMARY PHYSICIAN
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Phone
Address
OTHER PHYSICIAN
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