Welcome to 1st Care Management!
Here at 1CM, we aim to provide you with the best possible care within the comfort of your home. To get you started, please fill in the details on the following form. This will allow us to get to know you a bit better, and we will then be able to respond promptly and comprehensively on how we can address your needs.
Once you've completed the form, a 1CM representative will soon call you up on a number you'd have provided to establish care and plan ahead.
If you have any questions or queries, feel free to put them in the form towards the end.We look forward to working with you!
Yes
No
If Yes, you can upload by following the link below, or email/fax/mail it to 1st Care Management.
Alcohol Abuse
Anemia
Aneurysm
Anxiety Disorder
Arthritis
Asthma
Blood Disorder
Blood Clot
Blood transfusion
Cancer
Depression
Diabetes
Dementia
Drug Abuse
Glaucoma
Gout
Hay Fever
Heart Disease
Heart Murmur
Hepatitis B/C
High Cholesterol
HIV
Hypertension
Kidney Disease
Kidney Stones
Liver Disease
Seizures
Sexually Transmitted Disease
Sickle Cell Disease
Sleep Apnea
Stomach Ulcer
Stroke
Thyroid didsease
Tuberculosis
Positive TB Skin Test
Ulcerative Colitis
None
Bed-bound
Chair-bound
Significant difficulty moving around
Some difficulty moving around/ambulating
No difficulty moving around
Freely moving around in and out of the house
Do you have children?
Do you drink alcohol?
Do you smoke (cigarettes, e-cigarettes or vapes?
Have you ever smoked in the past?
Do you chew tobacco?
Do you use any recreational drugs?
Have you ever worked with asbestos or any other hazardous materials?
Do you have a living will?
Please read carefully the documents attached below, and sign them underneath by typing your name. If you're not the patient, please type in brackets your relationship to the patient. Zoom the page to be able to read it better, if need be. You may also contact 1st Care Management via phone or email for any questions.
Pneumovax
Flu
Tetanus
Hepatitis A
Hepatitis B
You have now completed the intake form. A representative will be in touch with you soon after your submission of the form, to guide you through the next steps and to initiate care. If you have any questions, feel free to contact at any of the following. You can also fax/email any documentation on the contact information provided.
Email: intake@1stcaremanagement.com
Phone: (833) 633-4778
Fax: (888) 622-6062
