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Name *

First

Last

Email *

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Questions you is

Phone Number

Your Role

• Owner/Administrator
• Nurse/Manager
• Support Staff/Other

Company Name *

Facility Type *--- Select Choice ---Assisted LivingGroup HomeMemory CareBehavioral Health/ResidentialAdult Day CareOther

Are you licensed?

• Licensed
• In Process
• Not Yet

Number of Residents (Capacity)

• 1-20
• 21-50
• 51+

How soon are you looking to implement software?

• Immediately
• Within 3-6 months
• Researching

Are you currently using software?Yes, we use softwareNo, we are using paper/spreadsheetsNot sure / just researching

Comments or Questions

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