New LifeStyles - Fort Worth

Winter/Spring 2014

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Information Request Simply complete this form and return it to New LifeStyles to receive detailed information from the communities or providers that meet your criteria. Seeking information for: (check all that apply) r r r r Retirement/Independent Living r Assisted Living Community Alzheimer's/Dementia Care r Nursing/Rehab Residential Care Home r Home Health Care Other____________________________________________________ City/Area(s) of Interest: _____________________________________________ ___________________________________________________________________ OR Community/Provider Name(s): ______________________________________ ___________________________________________________________________ ___________________________________________________________________ This information is for: ยก r r r r Myself Parents(s) Relative/Friend Other Anticipated Move Date: r r r r Less than 1 month 1-3 months 4-6 months More than 6 months Name______________________________________________________________ Address_____________________________________________________________ City_______________________________State__________Zip_________________ Phone (optional)_________________________________Date__________________ E-mail:______________________________________________________________ Where did you obtain your copy of New LifeStyles? ________________________ Mail completed form to: u New LifeStyles, Attn: Customer Care 4144 N. Central Expressway, Suite 1000 Dallas, TX 75204 Or FAX to: 866-817-8285 Phone : 800-869-9549 TAR W-S 2014 85

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