Nursing Home/Resident Appointment Request Form
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Section 1: Contact Information
Person Booking
Full Name of Person Requesting Service
First Name
Last Name
Relationship to Signer
Please Select
Self
Nursing home staff
Daughter/Son
Spouse
Legal representative
other
If other, please describe
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Perferred Method Of Communication
Call
Text
Email
Section 2: Resident/Signer Information
Full Name of Resident (Signer)
First Name
Last Name
Is the Resident the Person Signing the Document?
Yes
No (Explain).
If No, Please explain
How Many People Need Notarization?
Please Select
1 signer
2 signers
More than 2
Signer Email Address(optional)
example@example.com
Will any Witnesses Be Required?
Yes
No
No Sure
I Will Need Notary to provide Witness (applicable fee)
Section 3: Appointment Location
Signing Location Address
Building Name and Street Address (include ROOM NUMBER)
Street Address Line 2
City
State / Province
Postal / Zip Code
Facility Contact Person (Nurse/Admin)
Resident Room Number/Wing
Facility Phone Number
Are there any Entry Instructions?
Please Select
Check in at front desk
Ask for nurse station
Call upon arrival
other
Section 4: Document Details
Type of Document Being Notarized
Please Select
Power of Attorney
Healthcare Directive
DNR/Medical Forms
Property/Real Estate Documents
Financial Documents
Affidavit/Statement
Other (Please Explain Below)
Other:
How many Documents Need Notarization?
Please Select
1
2
3
4+
How Many Notarial Stamps are Needed? (if known)
Please Select
1
2
3+
Not Sure
Will the Document Be Ready at the Appointment?
Please Select
Yes
No, it still needs to be printed
Not Sure
Would you like Printing Services?
Please Select
Yes (+fee)
No
Upload Documents Here (Optional)
Browse Files
Drag and drop files here
Choose a file
Cancel
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Section 5: Signer Awareness & Capacity Screening
Is the Resident Alert and Aware Enough to Sign Willingly?
Yes
No
Unsure
Has the Resident Been Diagnosed with Dementia or Cognitive Impairment?
Please Select
Yes
No
Not Sure
Will the Resident be able to Communicate Directly with the Notary?
Please Select
Yes
No
Limited
Is anyone Pressuring the Resident to SIgn?
Please Select
Yes
No
Section 6: Identification Requirements
Does the Resident Have a Valid Government Issued Photo ID?
Please Select
Yes
No
Not Sure
Type of ID available
Please Select
Drivers License
State ID
Passport
Facility ID only
Other
If No Valid id: Would Credible Witness Be Available?
Please Select
Yes
No
Not Sure
Section 7: Scheduling
Request Appointment Date
Is This Urgent/Same-day?
Please Select
Yes
No
Any Facility Restrictions on Visit Times?
Please Select
Yes
No
Not Sure
What date and time work best for you?
Any other specific date and time, if the above selection is not suitable.
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
If you'd like to provide extra information:
Section 8: Payment Information
Who will be Responsible for Payment?
Please Select
Family Member
Resident
Facility
Attorney Office
Preferred Payment Method
Please Select
Cash
Invoice
Zelle
Invoice
Do You Approve Travel Fees For Mobile Service?
Please Select
Yes
No
Final Acknowledgement, by signing below I understand the signer must be willing, aware and able to communicate for notarizations to proceed.
Additional Notes or Special Requests
Other Services provided by the notary
Please Select
Certified Copy Certification
Apostille Processing
Courier Delivery Of Documents
After-Hours Emergency Notary (applicable fee)
Continue
Continue
Should be Empty: