Key Medical - Innovative Programs. Outstanding Customer Service.

Key Medical Supply Inc. 10th Anniversary. 1998-2008

Facility Information Form

We need a little information on the type of facility you have in order to be prepared to answer questions on your order. Please fill in the information below so we can have the correct information ready when we call you back.

Facility Information:

Please answer the few questions below so that we may provide the appropriate answers when we call you.

What type of facility are you?

Nursing Home
Assisted Living
Adult Foster Care-elderly
Adult Foster Care-developmentally disabled
Board & Care Home for the elderly
Other: Please describe

What is your position?

Director of Nursing
Director of Program Services
Caregiver
Other: Please describe

Are you interested in products for your clients or your facility?

Clients
Facility
Both

Additional Comments:

Address:
Include your name & your facility name.

Phone:

Email: