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Serving Tucson Area

jantaplin@yahoo.com

520-415-6363

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Request Dr. Jan to Speak

She speaks on a variety

of subjects tailored to meet

the needs of your audience

VIEW UPCOMING EVENTS

View PDF Versions of PowerPoint presentation slides below

Gain Independence and Age with Grace with In Home Assistance

Don't Get Caught with Your Pants Down

Reach out to us

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Contact Bob and Jan

Your First Name:

Your Phone number

The person needing assistance is

Me

My Mom

My Dad

My Grandfather

My Grandmother

My Aunt

My Uncle

My Neighbor

My Friend/ Acquaintance

Husband/ Wife/ Partner

Other

First Name of person needing care

What tasks are becoming more difficult?

Getting Dressed

Walking Safely

Shopping/ Errands

Cooking

Cleaning House

Remembering to take Medication

Organizing my Paperwork

Driving Safely

Making the Bed

Getting in the Shower Safely

My kids think I need help, I think I am doing just fine.

Keeping track of doctor appointments

Remembering what the doctor(s) told me at the appointment(s)

Your Email (if you have one)

Confirm that your phone and email are correct

Yes

Got it corrected!

How soon might you need care?

Gathering information at this time

In the next 24-48 hours

2-3 days from now

5-7 days from now

8-14 days from now

Next Month

Other important information about yourself and the assistance you are seeking.

Major cross streets or ZIP CODE

What are you most interested in/ or most need of? Check all that apply

Regular help in my home.

Someone to contact in Emergencies.

Someone to help manage and coordinate things.

This is all new to me, so I don't know what I need.

How did you hear about us?

Senior Fair

Read Article in Oro Valley Style Mag.

Google Search

Nextdoor

Pima Counsel on Aging Resource Guide

Heard Dr. Jan Speak at Senior Academy

Someone gave me your name/ card

IMPORTANT:

To protect your privacy, we ask only minimal questions on this form. We will ask more specific questions when we follow up via phone.

Also, if you do not hear back from us within 1 hour, please call 520-415-6363, as there could have been an issue with the message getthing through. We don't want to miss an opportunity to provice excellent care to you or your loved one.

Thank you,

Bob and Jan

Opt-In: A+ Elder Care Assistance does not use SMS messages, yet we are required to have the following opt-in statement:

“I agree to receive text messages from A+ Elder Care Assistance. I understand that message frequency varies and data rates may apply. I understand that I may opt-out by replying "STOP" at any time. I understand that I may reply "HELP" for assistance. I understand consent is not required to purchase goods or services.

If you choose to not "opt-in" please call the office at 520-415-6363, as this form will not be sent if this box is not checked.

Required Privacy Policy Statement:

“I agree with the Privacy Policy and Terms and Conditions”

Share my form:

By checking, I agree to share my form responses with A+Elder Care Assistance, and to receive a copy of my responses via email.

Thank you for contacting us.

If you do not hear from us within 2-4 hours, PLEASE CALL 520-415-6363 in case there was a glitch in the system.

Thanks Much!

Jan and Bob

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