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Senior Medical Questionnaire

  1. Do you live alone?
  2. Do you need assistance getting out of your home for things?
  3. Do you contact a family member or friend daily?
  4. Do you have a smoke / Carbon Monoxide detector in your home?
  5. Would you like our crews to visit your home for a free safety inspection?
      1. I hereby authorize the Loveland-Symmes Fire Department to maintain this record of my protected health information (PHI), and I have received a copy of Notice of Privacy Practices.
          1. Electronic Signature Agreement
            By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
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          3. This field is not part of the form submission.