Panora Assisted Living Services NEW SITE

Assisted Living Application

* designates required fields
Customer Name *
Customer Email Address *
example@example.com
Customer Mobile Number *
Customer Work Number
Joint Customer Name
Joint Customer Email
example@example.com
Joint Customer Mobile Number
Joint Customer Work Number
Physical Address *
City *
State *
Zip Code *
Billing Address *
City *
State *
Zip Code *
Directory Listing
Name of Closest Relative *
Relative's Phone *
Relative's Email Address
example@example.com
Where Are You Living?

Nursing Home Assisted Living Lakeside Village
Paperless Billing

Visit panorafiber.com to sign up for eBilling.
I do not wish to receive a paper bill. I understand that I can print off my bill if I choose from my online ebilling account.
Automatic Bank Payment
What type of account?

Checking Savings
Name of Bank/Credit Union
Account Number
Routing Number
Bank/Credit Union Address
City, State, Zip Code
Bank Phone
Signature

Clear
Customer Proprietary Network Information (CPNI)
We will confirm the identity of callers by asking them to provide the answer to an authentication question listed below. Certain call information will not be shared over the telephone regardless of authentication. Instead, you can: 1) have the information mailed to you; 2) have us call you back at the number on your account; or 3) pick up the information at our office. Authorized contacts can discuss account information and make changes to your account. Authorized contacts will not be responsible for payment of your account.
What is your favorite color? *
I do want to add authorized contacts, They are listed here
Check if you DO NOT wish to add authorized users
By ordering and accepting Service, you agree to adhere to our Terms and Conditions and Internet Acceptable Use Policy, including any modifications as we may communicate to you from time to time. You can find the Terms and Conditions on our website. We will also send you a copy of our Terms and Conditions if you send your written request to our business address as shown on your monthly bill. Prices in this application do not include taxes or USF charges.
Applicant Signature *

Clear
Date *

Month Day Year
A La Carte Services

All fees shown are charged on a monthly basis, unless otherwise noted
Fiber Voice

Residential Voice Service - $30.50
Prices reflect basic local residential service, including Call Forward, Call Waiting TouchTone, 911 and Subscriber Line Charge (SLC) fees.
Advanced Calling Features

Telemarketer Screening - $2.95 3-Way Calling - $1.00 Voicemail with eForward - $5.95 Caller ID - $3.00
Long Distance Services

PF Long Distance - 10C plan/$2.95 mo PF Long Distance - 14C plan/no monthly charge No, I don't want long distance features Yes, block 1-900 numbers Other - Please state provider code.
All voice service installations include a battery backup free of charge. This backup makes it possible for your corded, landline phones to work in the event of a power outage. In emergency situations, this will allow you to call 911 from your corded, landline phone. The battery backup is expected to last up to eight hours in the event of an outage depending on the battery age, usage and the environment. The batteries are rechargeable, but should be replaced every five to ten years. Extended backup batteries, which last up to 24 hours, are available for purchase. If you are interested in purchasing an extended battery, please contact our office.
Should be Empty:

Assisted Living Application

Paperless Billing

Automatic Bank Payment

Customer Proprietary Network Information (CPNI)

A La Carte Services