New Client Intake Form Please complete and submit this form at least 2 weeks before your surgery date. Email completed forms to: info@luxeconciergecare.com If you have any questions, please contact us at 813-616-2890. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 3General InformationLayoutName: *Today’s Date:PhoneEmail: *Address:Date & Time of Anticipated Service: Location of pick up (surgical, center, facility, hospital): Location of Service:LayoutHeight:Height:Emergency ContactsLayoutName & Relation: *Phone Number:NextMedical HistoryPrevious Surgeries:Previous Illnesses:Current Medical Conditions:Current Medications & Supplements, including dosages:Preferred Pharmacy Name & Address:Do you have any allergies to medications?Do you have any other allergies?Do you use any assistive devices such as; walker, cane, hearing aids, etc.?If so, what device(s) do you use?NextSocial HistoryOccupation: Do you use tobacco? If so, how much & how often? Do you use alcohol? If so, how much & how often? What are your food preferences and/or restrictions?What are your aromatherapy preferences?What are your biggest fears/worries regarding your upcoming surgery or recovery? Other things you think we should know?Choose Your Desire PackageFirst Item - $ 10.00Second Item - $ 25.00Third Item - $ 50.00Submit
