Become a Partner

Leverage the in care giving technology to enhance your nursing staff, improve resident communication, and reduce feelings of isolations and loneliness.

I am an:

IndividualAgency

Name of the Person To Contact * Relationship to Referral *

Email Address Phone Number

Person who needs SmartCompanion

First Name * Last Name *

Phone number *

Additional Client Info
How did you hear about us

Agency Information

Name of referring agency *
Name of Person submitting referral *
Email Address Phone Number
Address * City *
State * ZIP code *
How did you hear about us

Company Name(Required)

Agency Name(Required)

Entity Type(Required)

Company Address 1(Required)

Company Address 2(Required)

City(Required)

State(Required)

Zip Code(Required)

+ Add Locations

Company / Branch Name

Address 1

Address 2

City

State

Zip Code

Phone Number

How many years have you been in business?(Required)

How many active clients?(Required)

Are you looking to grow your private pay home care business?(Required)

Yes

First Name(Required)

Last Name(Required)

Your Phone Number(Required)

Your Email Address(Required)

How did you hear about us ?(Required)

Comments(Required)

checkbox 1(Required)

Our agency wishes to participate in the SmartCompanion program in accordance with the Subcontractor Agreement in the Terms & Conditions

checkbox 2(Required)

By Clicking Sign Up, you agree to our Terms & Conditions

checkbox 3(Required)

By submitting this document, I attest that I have the authority to execute this agreement on behalf of the above-named company

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