BON SECOURS CARE VILLAGE
LEE ROAD, CORK
CONFIDENTIAL APPLICATION FORM FOR LONG-TERM CARE
(Please tick) St. Josephs Hospital

Cedar Lodge Independent
Living Apts

NAME OF APPLICANT: ……………………………………………………………….
HOME ADDRESS: ..…………………………………………………………………….
……………………………………………………………………………………………..
TELEPHONE NO: …………………. MARITAL STATUS:………………………….
DATE OF BIRTH: ..…/……/…….. PLACE OF BIRTH:.…………………………
FORMER OCCUPATION: ……………………………………….……………………
MEDICAL CARD NO: ……………………….. EXPIRY DATE: ……………………
PENSION NO:.…..………………………… PPS NO: …………………………………
FAMILY CONTACTS
(NAMES)
RELATIONSHIP
TO APPLICANT
TELEPHONE/MOBILE
NUMBERS
NEXT OF KIN - FOR EMERGENCY PURPOSES
NAME: ……………………………………………………………………………………………………….
ADDRESS: …………………………………………………………………………………………………..
RELATIONSHIP: ……………………………….. TELEPHONE: ..………………………………………
CONTACT - FOR FINANCE PURPOSES (IF DIFFERENT)
NAME: ………………………………………………………………………………………………………
ADDRESS: ………………………………………………………………………………………………….
RELATIONSHIP: ……………………………….. TELEPHONE: ………………………………………..
SOLICITOR (IF ANY) IS THE APPLICANT A WARD OF COURT? Y/N ………………
NAME/COMPANY:…………………………………………………………………………………………
ADDRESS: ………………………………………………………………………………………………….
Page 1
BON SECOURS CARE VILLAGE
LEE ROAD, CORK
CONFIDENTIAL APPLICATION FORM FOR LONG-TERM CARE
GP
..…………………………………………………………………………
ADDRESS: …………………………………………………………………………
PHONE NO: …………………………………………………………………
P.H.N………………………………………………………………………………
ADRESSS:…………………………………………………………………………
PHONE NO:……………………………………………………………….
PHYSICAL CAPABILITIES
DO YOU NEED HELP WITH:
THE TOILET?
DRESSING?
TICK (if yes)
DETAILS
WALKING?
WASHING?
FEEDING?
DO YOU REQUIRE A SPECIAL DIET? (If yes please give details):
ARE YOU WILLING TO SHARE A ROOM?
ANY OTHER RELEVANT INFORMATION
INTERESTS/HOBBIES, ETC
FINANCE (SEE NOTES ON PAGE 5)
“FAIR DEAL” - APPLIED YES  NO 
APPROVED YES  NO 
(IF YES, PLEASE ATTACH A COPY OF YOUR APPROVAL LETTER)
OR
ARE YOU APPLYING AS A PRIVATE FEE PAYING RESIDENT? …………………
RELIGION (IF ANY): ………………………………………….………………………………
NAME OF PRIEST/PASTOR/IMAN etc: …………………………………….…………………
I CERTIFY THAT THE ABOVE DETAILS ARE TRUE AND ACCURATE TO THE BEST
OF MY KNOWLEDGE:
ONLY FULLY COMPLETED APPLICATIONS WILL BE ADDED TO OUR WAITING LIST
SIGNED: ……………………………………………………………………………….
RELATIONSHIP TO APPLICANT(IF NOT COMPLETED BY APPLICANT)
……………………………………………… DATE: …………………………………..
Page 2
BON SECOURS CARE VILLAGE
LEE ROAD, CORK
CONFIDENTIAL APPLICATION FORM FOR LONG-TERM CARE
MEDICAL FORM
(To be completed by your GP or Consultant)
Applicants Name: ……………………………………………… D.O.B.: ……………….
Home Address: ……………………………………………………………………………
………………………………………………………………………………………………
Current Location (If different): ……………….………………………………………..
………………………………………………………………………………………………
How long has he/she been your patient?: ……………………………………………….
MEDICAL HISTORY
(Give full clinical details, copy reports, if appropriate, also any test results & details of medication being taken)
CARDIAC SYSTEM: ……………………………………………………………………
……………………………………………………………………………………………..
RESPIRATORY SYSTEM ………………………………………………………………
…………………………………………………………………………………………….
URINARY SYSTEM (noting incontinence or otherwise): ………………………………
…………………………………………………………………………………………….
SKELETAL SYSTEM (details of fractures): …………………………………………..
……………………………………………………………………………………………..
MOBILITY: ………………………………………………………………………………
……………………………………………………………………………………………..
NERVOUS SYSTEM:…………………………………………………………………….
……………………………………………………………………………………………...
Has the patient been treated by the Psychiatric Service or been on Psychotropic medication:
………………………………………………………………………………………………
Is the patient rational/confused/co-operative/destructive/aggressive: ..……………….
Is the patient a danger to him/herself or others:...………………………………………
Page 3
BON SECOURS CARE VILLAGE
LEE ROAD, CORK
CONFIDENTIAL APPLICATION FORM FOR LONG-TERM CARE
MEDICAL FORM – cont.
SKIN DISEASES:…………………………………………………………………………
………………………………………………………………………………………………
MUSCULAR DISORDERS:……………………………………………………………
………………………………………………………………………………………………
INFECTIOUS OR TROPICAL DISEASES: .…………………………………………..
………………………………………………………………………………………………
ENDOCRINE SYSTEM: …………………………..…………………………………….
………………………………………………………………………………………………
SIGHT: …………………………………………..………………………………………..
HEARING:……………………………………..…………………………………………
ALLERGIES TO DRUGS:………………………………………………………………
LIST ALL CURRENT MEDICATION:………………………………………………...
………………………………………………………………………………………………
………………………………………………………………………………………………
Please give brief history of any changes in Mental or Physical health within the last year:
……………………………………………………………………………………………..
……………………………………………………………………………………………...
Has this person been assessed recently by a Geriatrician?:…………………………..
If so, by whom: ………………………………………………………………………….
(Please attach a copy of this report, if available.)
I know/have examined the above-named patient and have every reason to believe the
information given to me by the Applicant and/or representatives to be truthful and correct.
SIGNATURE & QUALIFICATIONS:…………………………………………………
ADDRESS: ………………………………………………………………………………..
PHONE NUMBER: …………………...………………… DATE:………………………
Page 4
BON SECOURS CARE VILLAGE
LEE ROAD, CORK
CONFIDENTIAL APPLICATION FORM FOR LONG-TERM CARE
Notes on admission to St Joseph's Hospital
St Joseph's Hospital has a total of 65 beds split into six units. A waiting list is maintained
for admission to all beds in the Home.
“FAIR DEAL” – Nursing Home Support Scheme
St Joseph's Hospital has been approved for the State’s Nursing Home Support Scheme
or “Fair Deal” as it is known, and maintains a waiting list of potential residents who
have been approved by the HSE under the scheme, and have chosen St Joseph's Hospital
as their preferred facility.
Applications for Fair Deal should be made to the HSE on form NHSS1 available on the
HSE website, or by contacting the HSE on 1850 24 1850, or your local HSE Health
Office on 021-4921835. The application process has two parts:
(1) A Care Needs Assessment
(2) A Financial Assessment.
Once approved for Fair Deal, you will be notified of the assessed financial contribution,
and receive a list of all approved nursing homes in the scheme. You can then choose any
nursing home on the list subject to the following two conditions:
(1) The home must be able to cater for your specific needs
(2) The home must have a place available for you.
Your assessed financial contribution will be invoiced to you by the Home monthly,
together with any additional charges not covered by Fair Deal, a list of these are available
on request or on admission. The HSE pays the difference between your assessed financial
contribution and the Fair Deal price of your chosen nursing home.
PRIVATE FEES
Should you not be eligible for, or decide not to avail of Fair Deal you may elect to pay
the total cost of care fee directly to St Joseph's Hospital, which will be invoiced directly
to you each month in advance. Admission will still be via our waiting list, and be subject
to our own assessment of need.
PAYMENT
Our preferred method of payment is a monthly standing order to an agreed value based on
the estimated amount to be invoiced each month. Details of our bank will be provided on
admission.
Further enquiries should be addressed to St. Joseph's Hospital on 021-4541566.
Page 5