Questionnaire For HSCL Wait-List
Please complete form to submit to wait list committee. You will be notified after review process.
Name of Perspective Resident *
Your answer
Contact Name *
Your answer
Contact Phone Number *
Your answer
Contact Email *
Your answer
Contact Address- used only for wait list purposes. *
Your answer
How did you hear about us
If other please explain
Your answer
Desired Move-In Time
What is the age of the perspective resident? *
Your answer
Briefly Describe Care Needs *
Your answer
Payment Type- Upon admission, what payer source can you anticipate? *
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