Senior Advantage Enrollment Form

(Please complete a separate enrollment form for each member)

Title:
First Name:
Last Name:
Phone:
Email Address:
Date of Birth:
Primary Care Physician:

Local Address
Address:
City:
State:
Zip:
Are you a Year Round Resident?:

Out-of-State Address (if applicable)
Address:
City:
State:
Zip:
What portion of the year do you reside at your out-of-state address?
As a member of Senior Advantage, I understand that information regarding services I receive from Wuesthoff Health System may be used for its healthcare operation. I also understand that certain information, including name, room and bed number, account number and Senior Advantage designation may be provided to Wuesthoff staff for the purpose of visiting me while I am an inpatient and for sending Senior Advantage informational mailings.