Questionnaire

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1 Step 1
First Name
DOB
date_range
Family Name
Spouses First Name
DOB
date_range
Spouses Family Nameyour full name
Address
Street Number
Street Name
City
Postal Code
Phone number
Cell Number
Please check one
Do you have any preferences where your retirement home should be located?
List city
When would you like to start looking for a residence?
Approx. Month and Year
Would you like to be in a residence where someone speaks your mother tongue or other language other than English
Do you have any dietary concerns? If so, please state
0 /
Are you on medication? If so, please let us know
Do you have mobility problems?
0 /
Ie. Walker Cane scooter
What type of accommodations would you be looking for?
Do you have any special requests? Please let us know
0 /
We Keep Your Personal Data Totally Protected. You Also Agree To Notify Seniors in Progress About Any Signing or Potential View of Any Retirement Home Without Notifying Seniors in Progress First.
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