Your Name
Your Email Address
Relationship
Safe Order - Your information is only used by AssistedLiving365.com, we do not sell or trade Emails and addresses. We only correspond by Email when sending account information. The SALBOT AI uses the phone number to send text alerts.
Private Home
1 Monitoring Requested By
Family
Friend
Caregiver
2 Elderly Client Information
3 Location of Installation
Gender
Age Group
Full Address
Room # /Apt #
Pets
50-69
70-79
80-89
90+
Special Observation Needed
City
State
Zip
Your Phone #
Special instructions or comments
Our office manager will contact you to set a meeting time and date
First and Last
