|
|
| Please print this form to your printer, complete the form and fax to 816-746-3886 or mail to Creative Care Consultants, 7200 NW 86th Street, Suite N, Kansas City, MO 64153. |
Name: _______________________________________________
Company Name:_______________________________________________
Address: _______________________________________________
City: _______________________State:_____Zip:_________
Phone: _______________________ Fax: _______________________
E-Mail Address: ________________________________
Please identify your relationship to the older/disabled adult or the reason for your inquiry:___ Family Member ___ Care Taker ___ Legal Guardian ___ Trust Officer ___ Healthcare Provider ___ Elder Law Attorney ___ Insurance Agent ___ Media Representative ___ Education Professional ___ Company EAP Representative ___ Estate Planner ___ Other (Please Specify) _________________________________ Additional Information You Wish To Share With Us: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ |