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Placement Inquiry Form

Thank you for choosing the United States ElderCare Referral Agency, we work hard to help you find the best living environment possible for your loved one.

Please fill out the form below and click the Send button. One of our representatives will respond to you as soon as possible. (Click here to view our privacy policy.)

 

Please tell us a little about you:

First Name:
Last Name:
Address:
Apt/Suite:
City:
State:
Zip Code:
Home Phone:
- -
Work Phone:
- -
Fax:
- -
Mobile Phone:
- -
Email Address:
   

 

Please provide us with a general idea of the type of living arrangement you are looking for:

Retirement Inn: Assisted Living:
Residential Board & Care: Skilled Nursing:
Price Range: (low) (high)
What area are you looking for?

 

Please tell us a little about the person you are looking for:

First Name: Last Name:
Age: Gender:
Their relationship to you: (Mom, Dad, Friend, Client, etc.)
Do they use a: Cane Walker Wheelchair
Do they suffer from Dementia? Yes No
  If yes, is it: mild moderate severe
  Do they wander? Yes No

 

Please complete a few general questions so that we may better assist you:

How would you like to be contacted? Phone Email Fax Letter / Report
How soon are you looking for placement? ASAP 30 days 60 days Future

 

Additional Comments:

 

 

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