First Name
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Last Name
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Email
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Phone
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Future Resident Name
Future Resident Age
Future Resident Gender
Future Resident Health Concerns
Ambulatory
Cardiac
Diabetes
Incontinence
LNS
Hospitalizations
Fall Risks
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Type of Home Interested in
Independent Living
Assisted Living
Memory Care
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What Amenities are Important to you
Nursing Care
Safety
Activities
Environment
Room Size
Dining
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What assistance do you currently have?
Home Health
Hospice
Family
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What is your timeline to move?
30 days
3 months
6 months
1 year
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Tell us more about the Future Resident's hobbies & interests
Tell us about how you have planned financially for moving into a community?
Long Term Care Ins.
VA A&A
Pension
Home to Sell
Life Insurance
Retirement Funds
Other
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Would You Like To Schedule A Tour?
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