To be completed by the primary care physician.

Villa Rose Senior Living Community, located in Bethalto, Illinois, is designed for seniors age 55 and older. Villa Rose offers affordable independent living with a blend of supportive services provided through a private-duty home care service. Villa Rose’s services promote security and peace of mind about health needs, and encourage aging in place. Services available on-site, but not required of each resident to obtain are:

¨ 24 hour staffing by home care aides

¨ medication reminders

¨ personal care including bathing, grooming and dressing

¨ escorts within the building

¨ companion service

Included in the monthly rental program are the following services:

¨ round-the-clock emergency response (staff members are required to alert emergency personnel in Bethalto to respond if a person has fallen or needs medical assistance).

¨ Three meals daily

¨ Light weekly housekeeping

¨ Provision of flat linens once per week

¨ Scheduled activities and transportation

All residents at Villa Rose must have the ability to live safely in the building and not pose a risk to themselves or others.

Based on the information described above,

(Insert name here)_________________________________________________

has the ability to live safely at Villa Rose Senior Living Community.

Physician’s Name_________________________________________________

Signature of Physician_____________________________________________

Office Phone_____________________________ Date____________________

Please return this form to: Villa Rose Senior Living Community

401 S. Moreland Rd.

Bethalto, IL 62010

Phone: 618-377-3239

Fax: 618-377-4636