Admission Application

We have placed an Admission Application on our web-site. After filling it out if you will click on submit it will be sent to our e-mail address. All Personal Information is kept confidential and will not be released to any outside companies, persons, etc unless you personally give written consent. If you would rather print off the form and mail it you may do that also. The address to send it to is: Peachtree Centre, 1434 North Limestone Street, Gaffney, SC 29340. Attn: Sandra Clark, Admissions Coordinator

Peachtree Centre Admission Application

Last name, First
Marital Status:
Birthdate:
Age:
Address:
City, State & County
Zip Code:
Resident's Physician:
Social Security Number:
Medicare#:
Medicaid#:
Insurance Info:
Type of Payment:
Are you a veteran or the spouse of a veteran?
Height:
Weight:
Diagnoses/Medical Problem:
Skin Condition:
Behaviors? (wandering, combative,hollering)
Check all that apply: Mentally Alert
Slightly Forgetful:
Confused:
Ambulatory:
Walks with assistance:
Chair-ridden:
Bed-ridden:
Continent:
In-Continent:
Feeds Self:
Requires feeding help:
Requires special diet:
Name of person inquiring:
Relationship to Resident:
Additional Contacts:
Interviewed By:
Signature:
Date:

If you have any questions concerning placement of a loved one please feel free to call:

Sandra Clark - Nursing Home and Short Term Rehab Admissions Coordinator Ext. 511

Cindy Matthews - Administrator Ext. 516

Autumn Cole - Director of Social Work Ext. 517

Lisa Jenkins - Assisted Living Admissions Coordinator Ext. 302

Peachtree Centre's phone number is 864-487-2717.

Have a great day!