First Name
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Last Name
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Phone
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Email
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City
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Do you live in or around the Dayton Ohio area?
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Please select YES or NO
What type of services are you looking for?
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Friendly companionship and conversation
Grocery shopping and errands
Light meal preparation
Light housekeeping and laundry
Help organizing the home
Appointment accompaniment
Safety-focused home check-ins
Medication reminders — without administering medication
How many visits do you need per month?
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Please select number of estimated visits monthly
Add any additional comments or information here
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Submit