Ridge Manor of Rossville Inquiry & Tour Request
Tell us about your loved one and choose the best time for our admissions team to call.
Contact Information
Full Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Relationship and Future Resident Details
Relationship to future resident
*
Myself
My parent
My spouse
Another family member
Professional referral (case manager, hospital, hospice, placement agency)
Payment, Veteran Status, and Timing
What type of stay are you looking for?
*
Long-term stay
Respite / short-term stay
Join the waitlist
Future resident name
First Name
Middle Name
Last Name
How do you expect to pay?
*
Private pay (savings, income, family)
Long-term care insurance
Veterans benefits (VA Aid & Attendance)
Georgia Medicaid waiver (EDWP / CCSP / SOURCE)
Medicaid application pending
Not sure — help me find out
Is the future resident a veteran or veteran's spouse?
Yes
No
Not sure
When are you looking to move in?
*
Immediately (within 2 weeks)
Within 30 days
1–3 months
3+ months / planning ahead
Current Situation and Care Needs
Care needs
Help with bathing and dressing
Help walking or transfers
Wheelchair user
Memory loss / dementia
Wandering risk
Diabetes / insulin
Oxygen
Incontinence care
Medication management
Hospice services
Tour Interest, Referral Source, and Additional Notes
Would you like to schedule a tour?
*
Yes — in person tour
Yes — video tour
Not right now
Preferred tour date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred tour time
*
Morning (9 AM–12 PM)
Afternoon (12–3 PM)
Late afternoon (3–5 PM)
How many people will attend the tour?
*
How did you hear about Ridge Manor?
Please Select
Google
Facebook
Case manager
Hospital or doctor
Hospice
Placement agency
VA / veterans organization
Friend or family
Other
Additional information
Consent
*
I agree that Ridge Manor may contact me by phone, text or email about this inquiry.
Request a Call
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