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4515 22nd Street NW
Canton, OH 44708
330-477-7664
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CAPITAL SENIOR
Mission Statement
Capital Senior
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Complete the form below to inquire about residency at Canton Regency
The first section of this inquiry should be filled out be the person inquiring about this property.
Name
Address
Phone
Email Address
Best Method of Contact
Phone
Email
Best time of day to contact
Morning
Afternoon
Evening
The second part of this inquiry should be filled out with information about the prospective resident.
Age
Select Age
55 - 65
66 - 75
76 - 85
86 - above
Marital Status
Select One
Single
Married
Widow/Widower
Name
Level Of Care
Select One
Assisted Living
Independent Living
Short Term
Health Care Center
Special Care Center
Required Assistance
(Please check all that apply)
Bathing
Dressing
Meals
Walking
Other Please explain:
Current Living Arrangement
Select One
Own Home
Rent Home
Living with Family
Senior Community
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The Canton Regency is a member of the Capital Senior Living family of communities>
