Senior Health Care Solutions

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HomeInquiry Form

Inquiry Form

Your Name*
Name of Potential Resident*
Age of Potential Resident*
Your Relationship to Potential Resident*
Your Phone Number*
Your Email*
Address*
Street Address Address Line 2 City State ZIP Code
How Did You Hear About Us?*
Is Potential Resident Currently Living at Home?*
- Yes
- No
Is your family member aware you are considering to place them with a healthcare provider?*
- Yes
- No
Is the patient in need of memory care or dementia services?*
- Yes
- No
- Unsure
Are you interested in a Private or Shared room?*
- Private
- Shared
Are you touring other centers?*
- Yes
- No
Which centers you are touring?*
When would you be looking to move in?*
Monthly Income*
Additional Information
Dementia Diagnosis?*
- Yes
- No
Wander Risk?*
- Yes
- No
Primary Care Provider*
City*
Date of Birth*
Primary Healthcare Insurer*
Additional Diagnosis
Special Diet*
Mobility Issues*
- Walker
- Cane
- Wheel Chair
- None
Incontinent?*
- Yes
- No
Evaluation Scheduled?*
- Yes
- No
Where?*
VA Eligible?*
- Yes
- No
- Unsure
Long Term Care Policy?*
- Yes
- No
Center Email