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Booking Form Confirmation
Please fill out the following health declaration form in order to book. Submissions are valid up to 24 hours prior to the activity.
First Name
Last Name
Email
Address
Phone
Birthday
Gender
My body temperature is lower than 98.6°F/ 37.5°C
Are you experiencing any flu symptoms?
No
Yes
Date
Initials
I confirm that the information given in this form is true
Are you taking any medication(s) or vitamin(s)? *
Choose an option
Medications
Name of Surgeon & Facility?
Number of Participants
Type of procedure(s)
Date of Procedure
Time of Procedure
How many SURGERY patients will be recovering in this suite?Â
Surgery sister's name?
List food preferences & food allergies:
I accept Stay RN's Cancellation Policy
View Cancellation Policy
I Accept Stay RN's Terms & Conditions
View Terms & Conditions
I Agree to Waive & Release Stay RN from any Liability
View Waiver & Release of Liability
Upload Photo ID
Upload supported file (Max 15MB)
By signing this form the you the client agree to a non refundable deposit of goods and services
Your Signature
Clear
Submit
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