Or use our handy online form:



Please select one: Mr. Ms. Your name: First: M. Last: Address: Street/P.O. Box: City: State: Postal Code: Telephone: Your e-mail required: (yourname@domain.com) How did you find us? Customer Referal WWW Search Engines Word of Mouth I would like to receive more information via: E-mail Telephone Call Regular Mail Regarding: Please Mark All That Apply Nursing Home Care Assisted Livng Apartments Hospice Care Adult Day Care Additional Comments:   Your IP address is being documented to prevent abuse of this form. You need only press submit once.  An e-mail containing all the information you've entered will be automatically forwarded to us. If you make a mistake, simply clear the form by using th clear button.

You may also stop in and visit our home or call for information and a tour. Ask for our Social Service Director. She will be pleased to show you around and answer any questions you might have. Call us at 618-488-2355 or email us at: hitzmemorial@agtelco.com.