In order to service you better we provide this simple request/referral form. Simply complete the indicated fields and click SUBMIT at the end. Your information will immediately be processed and the information you requested will be sent. We Care Adult Day Care takes your personal information seriously and will not use this information for any other purpose other than for what it was intended.

Date

Last Name First Name

Street Address:

City: State: Zip Code:

Phone: Email address:

 

In order to thank those who refer to our facility, we would like to know how you heard of us. Did you hear about us from a newspaper,a sign,a doctor, friend or other?

Would you like us to contact you ( phone, email, letter)?

Would you like us to send you our brochure and information (yes or No)?

Please tell us what services or information you are interested in.

 

Thank you. We will provide the information as soon as well receive this form

 

The Staff of
We Care Adult Day Care, Inc