Schedule A Tour | Affinity Skilled Living

Type*

Inquiry Date*

Inquiry Time*

:

Name of Caller / Visitor*

Caller / Visitor Contract #

Name of Resident*

Relationship to Resident*

Additional Contact Info

Current City or Residence or, Name of Hospital or, Name of Facility

Primary Reason For Seeking Placement*

Duration of Stay*

How Did You Hear About Us?*

Other*

Tell us how you heard about us:

In addition to general information regarding the facility, any specific questions, comments, concerns:

Name of Employee Completing Form*

Name of Employee Providing Tour (If Applicable)

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