Contact Us - PrepareFirst

To set up a safety consultation, please provide some basic information to let us know how best to contact you and to understand your safety goals. We will be in touch right away -- typically within an hour or two.

All information is optional, but the more you provide, the faster and more specifically we can assist you. The information you provide is kept strictly confidential and is never shared. If you wish to talk with us immediately, we welcome you to call the number at the top of your screen.

Your Contact Information
First Name
Last Name
Cell Number
Home Number
Work Number
Email
Should we list you as:	Mother Father Grandmother Grandfather Caregiver Other
Should We List a Second Contact Person?
First Name
Last Name
Cell Number
Home Number	Same as above
Work Number
Email
Should we list him/her as:	Mother Father Grandmother Grandfather Caregiver Other
Which of You Should We List As The Primary Contact?
You Second Contact Person
What Is the Property Address You Are Calling About?
Address Line 1
Address Line 2
City
State
Zip Code

Which of the following safety topics would you like help with?

	Child Safety
	Home Fire Safety
	First Aid / CPR
	Emergency/Disaster Planning
	Home Security
	Home Environmental Issues ( Mold / Radon / Water Safety / Chemical Safety / Air Quality / etc.)
	Senior Adult Safety

Is there anything in particular you are concerned about?

If you like, you may send us pictures of key safety issues to review:

Image 1:
Image 2:
Image 3:
Image 4:
Image 5:
Image 6:
Image 7:
Image 8:

If we'll be talking with you about child safety issues, please provide a bit of basic
information about the children in your home:

Boy / Girl	Years / Months	First Name (optional)
	/
	/
	/
	/
	/

Directions to Our Home from I-75 North:
(in case home is difficult to locate via GPS)

What would be good days and times for one of our consultants to visit?

How did you hear about PrepareFirst?

	Referred by a friend
	Referred by a physician
	Advertisement in
	Internet search
	Attended presentation at
	Other

Thank you very much for this information!

You will be hearing from us again shortly, typically within an hour or two.

If you click "SUBMIT" and do not immediately receive a confirmation page please call or email us.