Concierge Nursing Intake Form

Intake Form-Concierge Nursing

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.
Client Information

First NameLast Name
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of BirthAddress

MonthDayYear
Date
Age
Please list all allergies, medications, or supplements (include dose and frequency)
Please list any recent surgeries / procedures (type and date)
Concierge Nursing Services

All concierge nursing services are custom-quoted based on the level of care, duration, and individual client needs. Factors that may influence pricing include:

Type of nursing support required (post-operative care, medication management, wound/incision care, etc.)
Frequency and length of visits (hourly, overnight, or multi-day care)
Location and travel requirements
Any specialized equipment, supplies, or additional services requested0

You will receive a personalized care plan and pricing proposal following your intake consultation.
Client Initials (to confirm you have read and understand this section)
Where are you traveling from?
Destination(s)
Surgery Date

MonthDayYear
Date
Type of Surgery
If other, please specify
Level of assistance needed
Chronic Health Conditions
If other, please specify
Please specify
Do you require mobility assistance?
Please indicate any mobility assistance you require:
Do you use medical devices?
Do you use or travel with any of the following medical devices or equipment?
Oxygen Type (Portable Concentrator / Tanks)
Flow Rate
Battery Hours / Backup Supply
Dietary Restrictions
If Other, please specify
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?
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.Format: (000) 000-0000.
Relationship to You
Secondary Emergency Contact

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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

Concierge Nursing AcknowledgmentI understand that Stacybug Adventures LLC provides private nursing services under the name of Stacybug Concierge Nursing. I acknowledge that these services are professional nursing in nature and will be delivered in accordance with my individualized care plan and the Service Agreement. By signing below, I confirm that I have reviewed and agree to the terms and conditions of service.Confidentiality & HIPAA AcknowledgmentI understand that any personal health information I provide will be kept strictly confidential in compliance with HIPAA regulations. My information will only be used for the purposes of delivering care and will not be shared without my written consent, except as required by law..
Signature
Date

MonthDayYear
Date
Additional Information
Form Version 1.0 - Updated September 2025
Calculation
Should be Empty:

Intake Form-Concierge Nursing