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Alzheimer's Association Greater East Ohio Area Chapter

Karen Elliott

Address: 408 9th Street SW Suite 3400 Canton, OH 44707

Phone: (234) 284-2750

Fax: (330) 777-5811

Email: geoachl@alz.org

Provider:

Provider organization:

Provider phone:

Provider email:

Provider fax:

Name of person with memory loss:

Name of person being contacted:

How is the person being contacted related to the person with memory loss?

Self

Other

Phone:

Email:

Mailing address:

City:

State:

Zip code:

Preferred method of contact:

Phone

Mail

Preferred day/time of contact:

Monday - Friday between 8am - 4pm

The person being referred provided verbal consent instead of their signature

I accept the legal terms and conditions

24/7 Helpline 800-272-3900 / www.alz.org