SMK CARINGS HANDS

OUR CONTACT INFORMATION

SMK Caring Hands,
900 Lawrenceville Highway Suite 111-214
Lawrenceville, GA 30046

Phone: 770-200-4000
Email:SMK@SMKCARINGHANDS.com

Need Care of a Loved One? Fill out the Prospective Client Form below


You may also send us a comment or question






Prospective Client -Needs care of a loved one.

If you are a prospective client who needs care for a loved one, please fill the form below and we will contact you for a consultation.


Contact Information

For the person requesting information please provide the following information. (* indicates required information)

Your Name*:
  Address*:
    City/State/ZIP*:
  Phone Number *:
Best time to contact*:
Email :
         

About your loved one

For the person in need of care please provide the following information:
Relationship


Address* :

City/State/ZIP*:


Current Living Arrangements
   Assistance needed
Please tell us the care needed by selecting all that apply below. You may share additional information in the appropriate area below:

Alzheimer's
Live-in Care
Companionship
Bathing
Dressing
Eating		 Medication Reminders
Meal Prep.
Housekeeping
Laundry
Errands
Toileting
Other

How many hours per day is the care needed?*

  

Rate your loved one's receptiveness

How soon do you need care?*

How did you hear about us?

You may share any other information:

       
Back to TOP
Go Back to Previous Page