Request a Brochure

For whom are you requesting information?
(Please select all that apply)

Myself

Parent or In-Law

Grandparent

Other Relative

Friend

Requested By:       *

Company Name:     

Address:                 *

Suite #:                         City:  *

State                        *    

Zip  Code:               *

Phone:                     *       Fax: 

E-Mail Address:     *

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Which levels of care are you interested in?
(Please select all that apply)

Independent Living

Assistance in Living

24 Hour Skilled Nursing

When are you interested in making a move to a community?
(Please select one)

Within 30 days
Within 60 days
Within 90 days
Within 6 months
Within 1 year
Within 1-2 years
More than 2 years

How did you hear about One Kalakaua Senior Living?
(Please select one)

Link from another site
Newspaper
Magazine
TV/Radio
Direct Mailer
Newsletter
Yellow Pages
Referral
Other

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