EL-AGED GERIATRIC CARE HOME INQUIRY FORM 
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Your name *
Your phone number *
Email address *
Your current location *
Who are you making inquiry for?
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Do you have the necessary medical records for your loved one?* *
How old is your loved one?
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Is your loved one independent, semi-dependent, or fully dependent 
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How  did you hear about EL-AGED GERIATRIC CARE HOME?
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Are your looking for short-term, long-term or respite care
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Would you like to speak with our care team to discuss a personalized care plan?
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Would you like to schedule a facility tour or consultation?
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Does your loved one have dietary restrictions or special feeding needs 
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Is your loved one currently on any medication 
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Does your loved one require assistance with daily activities  *
Would your loved one be comfortable in a community setting or prefer private care? *
Do you have a budget in mind for their care?
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Does your loved one have any behavioral concerns 
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Required
Does your loved one have any medical conditions?
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Would you prefer an in-person or virtual assessment for your loved one?
 *
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