Information Request Form

Contact Information

Please use the form below to request more information about programs and services provided by McLaren Homecare Group. Do not use this form in a medical emergency of any kind.

If you are requesting home health services for either yourself or a loved one, please note that submitting this form does not mean care will automatically begin. Specific criteria must be met for home health care services to begin and a physician authorization is required. The information you provide will be sent to our home health care team, who will respond to your request to address your questions/concerns and can assist you with coordinating the process.

* Indicates required information

Patient/Client Name: *
Address*
City: *
State: *
Zip Code: *
Email Address:
Home Phone:
Cell Phone:
If you are a physician or are from a physician’s office, please provide the following information:
Name of Physician:
Physician Phone Number:
Please tell us about your reason for contacting McLaren Homecare Group (choices below are in a drop down format):




Comments / Questions
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