Intake Form-Travel Companions

Intake Form-Travel Companions

Stacybug Adventures LLC operates under multiple service lines, including Stacybug Concierge Nursing and Stacybug Travel Companions. All references to Stacybug Adventures LLC in this Agreement also apply to its affiliated service lines.
This intake form helps us understand your health background, mobility, preferences, and travel needs so we can best support you.
Traveler Information

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Please list all allergies, medications, or supplements (include dose and frequency)
Please list any recent surgeries / procedures (type and date)
Please note: All travel companion services are custom quoted. Flight costs for both the client and the companion will be included in your personalized estimate, which will be provided after we receive your intake form. If any overnight stays are required, the client is also responsible for covering a separate hotel room for the companion, which can be arranged adjoining the client’s room if needed.
Client Initials (to confirm you have read and understand this section)
Where are you traveling from?
Destination(s)
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Traveler Type

Senior TravelerMinor Traveling AloneAdult with Medical ConditionSolo Traveler
Trip Duration

Domestic under 4 hoursDomestic 4-8 hoursDomestic 8-12 hoursInternational FlightMulti-day or multi-leg trip
Seat Preference (for flights)

WindowAisleMiddleNo Preference
Do you require assistance with luggage?

Assistance with checked bag at airportCarry-on handlingOversized/medical equipment (wheelchair, scooter, oxygen, etc.)No assitance needed
If oversized/medical equipment, please specify
Level of assistance needed

Basic navigation only (check-in, boarding)Help with mobility (wheelchair, luggage, transfers)Medication reminders or light medical oversightFull hands-on support throughout the trip
Additional Services (check all that apply)

Overnight stay is requiredMultiple transfers or layoversEscort beyond the airport (hotel, camp, family home, assisted living, nursing home)Concierge nursing care during the trip
Please provide details about the escort services you require beyond the airport (e.g., to hotel, medical appointments, family residence, etc.)
Chronic Health Conditions

Heart DiseaseDiabetesRespiratory IssuesNeurological ConditionsMental Health Condition (anxiety, depression, PTSD, other)Other
If other, please specify
Please specify
Do you require mobility assistance?

YesNo
Please indicate any mobility assistance you require:

CaneWalkerWheelchairTransfers (Car <--> Chair)Bathroom AssistanceLong-distance walking supportMobility ScooterOther
Do you use or travel with medical devices?

YesNo
Do you use or travel with any of the following medical devices or equipment?

Oxygen (portable concentrator, tanks)CPAP / BiPAP machine (for sleep apnea)Nebulizer (for asthma/COPD)Feeding tube equipment (G-tube supplies, portable pumps)Catheter Supplies / urinary drainage bagsColostomy / ileostomy suppliesInsulin pump or continuous glucose monitor (CGM)IV / Infusion pumpPortable suction deviceHearing Aids / Cochlear Implant AccessoriesOther
Oxygen Type (Portable Concentrator / Tanks)
Flow Rate
Battery Hours / Backup Supply
Dietary Restrictions

Gluten FreeVeganVegetarianHalalKosherOther
If Other, please specify
Would you like to provide physician contact information?*

YesNo
Primary Care Physician / Specialist Name
Physician Phone Number
Providing this information is optional but may help us coordinate care in an emergency.
Would you like to provide insurance information for emergency use?*

YesNo
Insurance Provider
Policy Number
Providing this information is optional but may help us coordinate care in an emergency.
Emergency Contact

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to You
Secondary Emergency Contact

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to You
This person will only be contacted if your primary emergency contact cannot be reached.
How did you hear about Stacybug Adventures?
If other, please specify
Consent

I understand that Stacybug Adventures LLC provides travel support services under the name of Stacybug Travel Companions. I acknowledge that these services are non-medical in nature and are provided as outlined in the Service Agreement. By signing below, I confirm that I have reviewed and agree to the terms and conditions of service.
Signature

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Date

MonthDayYear
Date
Additional Information
Form Version 1.0 - Updated September 2025
Total Score
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