Proposal Request

If you would like to receive a proposal from MJ Care, we will need some information about your current therapy needs. All information will be kept strictly confidential. Required fields are marked with an asterisk.

Your Information

*Name

*Address

*City

*State

*Zip

*Phone

*Email

*Facility

Facility Size

Total Beds

Medicare Beds

Enter Medicare A Census/Caseload

Enter Medicare B Census/Caseload

Assisted Units

Independent Units

Days Per RUGS Category for the past 6 months:

Ultra High

Very High

High

Medium

Low

Independent Units

Extensive Services

Clinically Complex

Special Care

All Others

Staffing levels per month:

PT hours per month

OT hours per month

SLP hours per month

Timeframe for changing providers:

I would like more information about:

Current

Future

Outpatient Program

Vitalstim Therapy

Dementia Treatment

Wound Care

Other