CLIENT INTAKE FORM

CONTACT INFORMATION

For Client/Patient Requiring There When Needed Services
All fields are required, and a cell phone is preferred as text messages can be utilized for communication. If you do not have a cell phone, please place your phone number in the “Other Phone” field.
Name
First and Last Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Cell Phone is preferred, as text messages can be utilized for communication. Format: (000) 000-0000.
Other Phone
If you do not have a cell phone please enter your phone number here.Format: (000) 000-0000.
Email
example@example.com
Date of procedure

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type of Procedure
Name and Address of Medical Facility where procedure will be performed

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Required Check In Arrival Time
As specified by medical facility
Estimate of Length of Procedure from Prepping to Recovery
You can ask your physician
Transportation
There When Needed cannot provide transportation at this time and suggest that you secure a ride with Uber / Lyft or another transportation option; There When Needed can provide transportation services contact information upon request.

There When Needed can inform your driver what time you will be discharged, so that their vehicle is at the discharge exit when There When Needed accompanies you and the attendant wheeling you to the exit.
Do you have a family member or friend who can drop you off at the medical facility?
Do you have a family member or friend who can pick you up when discharged and drive you home?
Person Picking You Up

Contact Info (If known now) of driver picking you up:
Name

First NameLast Name
Phone Number
Cell Phone is preferred, as text messages can be utilized for communication. Format: (000) 000-0000.
If NO, There When Needed will drive you to your home. If you are going to an address different than that listed at the top of this form, please specify that address here.

Street Address

Street Address Line 2

CityState

Zip Code
Your Current Mobility
Are you ambulatory and able to walk and get in and out of a vehicle easily?
If you are not ambulatory and have appropriate transportation arranged to and from the procedure, There When Needed is happy to meet you in the surgical registration check-in desk and be “your person in the waiting room” so your procedure can be completed!
Anything Else You'd Like Us to Know About You?
Should be Empty:

CONTACT INFORMATION

Transportation

Person Picking You Up

Your Current Mobility