Request a device – Music at Last Society

Your name (person completing this request) *

First

Last

Email *

Telephone or mobile

Relationship to person you are completing this request for

PLEASE COMPLETE INFORMATION BELOW ABOUT THE PERSON YOU ARE REQUESTING A DEVICE FOR *

First

Last

Birth Date (YYYY-MM-DD) *

Enter the birthdate of the person you are requesting a device for

Diagnosis (e.g. Alzheimer's)*

Stage of dementia *

Does this person live in a care home or with family? Tell us a little bit more about your loved one.

Music genre - please click on all preferences that apply *

OTHER (Please specify)

If you are aware of specific songs, authors or titles your loved one enjoys, please share this information with us below.

If you would prefer we collect this information in person or by telephone, it would be our pleasure to accommodate you. Please specify below your preference and timetable.

Feel free to add any additional information you feel will help us in compiling a personalized musical experience for your loved one.