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Post-Operative Recovery Care — Inquiry

Please provide the information below to request availability for short-stay post-operative recovery support. Submitting this enquiry does not confirm a booking.

1. Full Name

(First and Last Name)
[Text]

2. Phone Number

(Best number to reach you)
[Phone]

3. Email Address

[Email]

4. Are you completing this form as the client or on behalf of someone else?

• ☐ I am the client

• ☐ I am completing this form on behalf of the client
  [Multiple Choice]

5. Type of Surgery

(Please specify the procedure)
[Text]

6. Date of Surgery

[Date]

7. Surgical Facility Name

[Text]

8. Location of Surgical Facility

[Text]

9. Is the client expected to be discharged as medically stable and ambulatory?

• ☐ Yes

• ☐ No

• ☐ Not sure
  [Multiple Choice]

10. Desired Start Date for Recovery Stay

(Typically the day of discharge)
[Date]

11. Length of Stay Requested

• ☐ 3 days

• ☐ 4 days

• ☐ 5 days
  [Multiple Choice]

12. Will transportation support be needed?

(Check all that apply)

• ☐ Pick-up after day surgery discharge

• ☐ Return transportation for first post-operative follow-up visit

• ☐ Transportation not needed
  [Checkboxes]

13. Does the client have any mobility limitations we should be aware of?

(For example: walker use, assistance required, balance concerns)
[Short Text]

14. Please confirm the following acknowledgments

(Required)

• ☐ I understand this is a non-medical, short-stay recovery support service

• ☐ I understand this service does not replace medical care or home health services

• ☐ I understand availability is subject to review and confirmation

[Checkboxes — required]

15. Additional Information or Questions

(Optional)
[Long Text]