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Name
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First
Last
Email
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Best phone number
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Who requires caregiving support? (Choose all that apply)
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Mother
Father
Grandmother
Grandfather
Uncle/Aunt
Friend or Loved one
What conditions are your loved one currently exhibiting?
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Diabetes (Type II)
Heart disease
Cancer
Arthritis
Hypertension
Not certain
Place of care, where does your loved one reside...
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They live alone
He/she lives with me
Currently in a facility
Anything else you want us to be aware of?
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Name
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First
Last
Email
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Who needs Proxie?
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Parent
Grand Parent
A friend
Myself
What's the urgency of your need?
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Urgent (Immediately)
High Priority (Within 3-6 months)
Medium Priority (Within 6-12 months)
Low Priority (Longer than 12 months)
Known conditions
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Diabetes Type II
Hypertension
Arthritis
Heart Disease
Cancer
No known conditions at this time
Care receiver zip code
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