Salutations:
Ms.
Miss
Mrs.
Mr.
* First Name:
* Last Name:
City:
* State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
* Zip Code:
* Phone:
x
Cell No.:
x
* Email:
Fax:
x
How do you wish
to be contacted:
Phone
Cell
Fax
Email
What is the
best time to contact you?
AM = 9am - 12 noon
Afternoon = 1pm - 4pm
PM = 5pm - 7pm
Comments and Questions:
All client information is kept completely
private and confidential.
THE GOLDEN JOURNEY PRIVACY POLICY
The Golden Journey values and respects
our clients’ privacy and will do all we can to uphold it. We
recognize both a legal and ethical responsibility to protect
the privacy of our clients. Therefore, there will be no
indiscriminate or unauthorized review, use or disclosure of
personal information, medical information, or other private
information regarding any client or relation to the client.
We do not rent, sell, trade or otherwise release or
disclose any personal or financial information about our
clients or our client’s families. We do not supply any
information to anyone outside The Golden Journey
unless expressly approved by our client(s). Upon such
permission, we may disclose information to those individuals
and/or professionals approved by the client and who service
or may service the client. Otherwise, we do not disclose any
non-public personal information about clients or former
clients to anyone, unless authorized by the client or as
required by federal or state or local law.
We restrict information about clients or families to those
individuals and/or professionals who help to serve the
client. We require any such individual and/or professional
to protect the confidentiality and privacy of the client and
to use that information solely and only for the purpose for
which it is disclosed.
Clients of The Golden Journey are
welcomed to request copies of all forms relating to their
services and those forms will be supplied to them in a
reasonable amount of time. Such forms are for filing and
reference purposes only and originals are not relinquished
to anyone; originals are to remain in the client file.
The Golden Journey reserves the right to
modify or remove parts of this privacy statement at any
time. We will notify clients in advance of any changes that
may effect your rights under this policy statement.
Employees of “THE GOLDEN JOURNEY” are not
and do not claim to be attorneys, physicians, medical
personnel or financial advisers. All clients of “THE
GOLDEN JOURNEY” are advised to research,
investigate and/or analyze each and every referral and make
any and all decisions based upon that research,
investigation and/or analysis. Any and all referrals or
members of the network or professionals of THE
GOLDEN JOURNEY are not employed by or compensated
by anyone affiliated with THE GOLDEN JOURNEY .
THE GOLDEN JOURNEY and its associates do not
guarantee or allude to any guarantee of the performance of
any referral. Each member of network or professionals
provides his/her/their own liability insurance and is not
insured by THE GOLDEN JOURNEY.