4901 Waters Edge Dr.
Suite 200
Raleigh, NC 27606
P: (919) 852-4000
F: (919) 852-4001

Inquiry Information Form

Thank you for your interest in Carillon Assisted Living. To help us provide you with the most appropriate information possible, please complete and submit the following form.

Name:
(First)
(Last)
Email:
     
Name of Potential Resident:

Are you looking for assisted living options for:
      Self
      Spouse
      Family Member
      Friend

For yourself or the person for whom you are inquiring, which best describes the current living situation:
      Live in own home independently (not using home health care)
      Live in own home and receiving home health care
      Live with family members/friends
      Live in a community for independent seniors
      Live in an assisted living community
      Short-term stay in a nursing home

How soon do you think you will need assisted living services?
      Immediately
      Within 3 months
      Within 6 months
      Within a year
      Not sure – just gathering information

Which type of service do you feel you will need?
      Assisted Living
      Alzheimer’s/Dementia care
      Respite
      Not Sure

Which Carillon Assisted Living communities would you be interested in?

  Asheboro Cramer Mountain Fayetteville
  Fuquay-Varina Harrisburg

Hendersonville
  Hillsborough Lincolnton Monroe
  Newton Salisbury Shelby
  Southport Raleigh (Corporate Office)

Please enter any comments or questions you have about Carillon Assisted Living below:

       

If you wish to receive an information packet by mail, please complete the following information:

Mailing Address:

(City)
(State)
(Postal Code)

If you would prefer to receive a phone call from one of our Marketing Directors, please provide the information below.

Phone Number:
Best Time to Call:    AM    PM