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 Remit to: 19 Beach Road Salisbury, MA 01952 Tel: 978-463-9809 Fax: 978-463-3009

Name:_____________________________________________________________________________

Street:_____________________________________________________________________________

City:_____________________________________State:__________________ Zip:_______________

Telephone:_________________________________________

Fax:_______________________________________________

Email:_____________________________________________

Would you like us to contact you immediately to discuss your needs? Y / N

*Are you inquiring for: (circle)

yourself parent grandparent friend other
 
If you choose "other", please specify:______________________ Age:________

*If you are inquiring for someone other than yourself, please answer the following questions with information on that person.

How soon would you need placement? (circle)

One month 3 months 3 months to 1 year not sure

What is your current living situation? (circle)

Home independently  with family temporary nursing home / rehab hospital other

Other comments:___________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________
How did you first hear about us? (circle)

Director of Nursing facilities family or friend told me I saw your sign when driving by
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