New Client Enrollment

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No commitment required. Completing this form simply alerts our team to your interest. A registered nurse will review your information and follow up within one business day to answer questions and guide next steps.

Choose Path

Contact Info

Client Details

Preferences

Who needs care?

Select the care type that best describes your loved one. This helps us prepare the right questions for your situation.

👶

Pediatric / Child

For children and young adults with complex medical needs. Includes GAPP, G-Tube, and Medicaid programs.

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Senior / Adult

For elderly adults needing personal care, medication management, companionship, or hospice support.

How did you hear about us? *

Your Contact Information

Tell us about the person filling out this form — the parent, guardian, or family contact.

First Name *

Last Name *

Phone Number *

Email Address *

Street Address *

Apartment / Unit #

Child's Information

Please provide details about the child who will be receiving care.

Child's First Name *

Child's Last Name *

Date of Birth *

Weight (lbs)

Medicaid Number

If you don't have it handy, you can provide it later.

Primary Diagnosis / Medical Condition *

Currently in School or Daycare?

Yes No

Active IEP (Individualized Education Program)?

Yes No Unsure

IEP Copy Available?

Yes No

Contact Preferences

Almost done! Let us know the best way to reach you.

Preferred Contact Method *

📞 Phone Call 💬 Text Message ✉️ Email

Best Time to Reach You *

🌅 Morning ☀️ Afternoon 🌆 Evening

Additional Notes or Questions

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Your privacy is protected

Your information is used solely to contact you about care services. We never sell or share your data. All communications are confidential.

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You're all set!

Thank you for reaching out to EMIC Home Care. A registered nurse will review your enrollment and contact you within one business day.

If you need immediate assistance, call us directly at 470-591-3111

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Who needs care?

Pediatric / Child

Senior / Adult

Your Contact Information

Child's Information

Client Information

Contact Preferences

Your privacy is protected

You're all set!