Name *

First Name

Last Name

Phone

(###)

###

####

Preferred Method of Contact *

Phone

Email

Either

Which home are you enquiring about? (Select one or more) *

Dunwood Manor Nursing Home (Romsey – Aged Care)

Waverley Lodge Nursing Home (Romsey – Physically Disabled Adults 18–65)

Not sure yet

What type of care are you enquiring about? (Select all that apply) *

Nursing Care

Dementia Care

Short Stay / Respite Care

End-of-Life / Palliative Care

Physically Disabled Adult Care (18–65)

General Information

Schedule a Visit

Others

Have you visited any of our homes before? *

Yes

No, but I’d like to schedule a visit

No

Who is the care for? *

Myself

A family member

A friend

A professional referral

Other

Preferred Admission Date (if known)

MM

DD

YYYY

Would you like us to email you a brochure or additional information?

Yes

No

By submitting this form, *

I agree to be contacted by Ikshana regarding my enquiry. I also understand that my information will be handled in accordance with the privacy policy.