American Senior Network || Client Quotes

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Complete the form below to receive a quote
If you would like a quote for a spouse, please complete an additional application with their information.
First Name *
Last Name *
Street Address
City
State
Zip Code
Phone Number *
Best time to call
E-mail Address
Date of Birth
Gender	Male Female
Association
1) Do you currently need or receive assistance or supervision performing everyday living activities, such as walking, bathing, dressing, eating, transferring or toileting?
Select your answer here:	Yes No
2) Are you currently confined to a hospital, nursing home, assisted living facility are you receiving any type of care or assistance in your home?
Select your answer here:	Yes No
3) Do you use oxygen continuously or a walker or a wheelchair more than once per week?
Select your answer here:	Yes No
4) Have you ever been diagnosed with or treated for:
Mental Retardation, Alzheimer's Disease, Dementia, Senility or any type of Organic Brain Syndrome or Disorder, Schizophrenia, or consulted a physician about memory loss, forgetfulness or confusion?	Yes No
Acquired Immune Deficiency Syndrome (AIDS) or AIDS-related Complex (ARC), or tested positive for the Human Immunodeficiency Virus (HIV)?	Yes No
ALS (Amyotrophic Lateral Sclerosis or Lou Gehring's Disease), Cerebral Palsy, Charcot Marie Tooth, Cystic Fibrosis or Muscular Dystrophy?	Yes No
5) Have you ever tested positive for Huntington's Chorea?
Select your answer here:	Yes No

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