The Maine Dementia Care Partnership, a coalition to improve dementia care co-chaired by the Maine Ombudsman Program, Maine Healthcare Association, and Jabbar Fazeli, MD, has partnered with Memory-Lane.TV, based in Portland, Maine, to provide 60 nursing homes free access to Memory Lane TV, a non-pharmaceutical dementia care intervention, for two years. This form is designed to formalize the registration of your institution.

Please enter the following information

Name of your Institution

Name of the primary contact person(Required)

First Last

Role/Title

Contact Email address(Required)

Account email address to be used as account ID(Required)

This email will serve as the account ID, so it might be different from the contact’s email, or not.

Please confirm the following pre-requisites are currently in use/will be installed prior to start of service:

We have broadband internet service at the location where Memory Lane TV will be used.(Required)

Yes

No

No, but we will be able to get service prior to start of MLTV service

Do you currently have a suitable HD or 4K TV in place – ideally in common area in the memory care unit?(Required)

Yes

No

No, but we will be able to get service prior to start of MLTV service

Are you currently using any of the following streaming devices in your facility that can also be used for MLTV (check all that apply)?(Required)

Roku

Apple TV

Amazon Firestick

Google Chromecast

We do not have a compatible streaming device currently, but will obtain & install one prior to start of service

We do not have a compatible streaming device currently and DO NOT intend to get one

Additional questions or comments for the Memory Lane TV team (please enter in the box below)

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