Intake Form

This form gathers essential details about your care needs, service preferences, and contact information. Please ensure it’s filled out entirely. Once submitted, we will review your information and provide you with a personalized Service Care Agreement (via email) within 1-2 business days.

Please note: This form does not obligate you to any service, however, your reservation will not be confirmed until you have signed your Service Care Agreement and paid the 50% non-refundable fee to reserve your spot. We accept reservations up to 3 months in advance.

Your privacy matters. All Service Care Agreements contain a Privacy Clause and we adhere to all HIPAA regulations.

If you have any questions while filling out the form, please don’t hesitate to reach out. We look forward to assisting you on your recovery journey!

Client Information

First Name

Last Name

Email

Phone Number

Emergency Contact (name/phone)

Service(s) Requested

Package 1: Medical Transportation

Package 2: Essential Recovery (4hr)

Package 3: Comprehensive Recovery (8hr)

Package 4: 24hr Recovery Care

Date of Procedure

MM

DD

YYYY

Anticipated Pick-Up Time

Pick-Up Location

Drop-Off location.

Physician Information

Allergies or Medical conditions relevant to aftercare

Paient Height & Weight

Additional Information

Client Responsibilities

You acknowledge that all information provided will be used to create your Service Care Agreement. There is a 50% non-refundable deposit required to complete your reservation. Restrictions may apply.

Client Agrees

Client Does Not Agree

Intake Form

CLIENT INTAKE FORM

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