Elm Terrace Gardens
LANSDALE, PA 19446-2361
(215) 361-5600

For more information on Elm Terrace Gardens, please fill out and submit the following form, or call us at (215) 361-5600.

Please also feel free to contact Sandi Vereb, Sales Associate, at 215-361-5656.

1. Please provide the following information so we may
   contact you in a timely manner:

   Name:
   Street address:
   Address (cont.):
   City:
   State:
   Zip code:
   Work Phone:	Area Code
   Home Phone:	Area Code
   E-mail:

2. Inquiring for: Self     Self & Spouse    Other
   
3. Level of Care: (Choose one or more of the following.)
   Independent/Residential Living
         Studio/Efficiency    One Bedroom    Two Bedroom
   Personal Care
   Nursing Care
   
4. Required Date of Residency:
   Immediately    6 Months    1 Year   Wait List
   
5. Questions: