Client Assessment Form – Rapid Recovery Rx

Do you have any medical conditions? * *

Yes
No

Please list all medical conditions. *

Are you allergic to any medication or food? If so please list below. * *

Do you agree that Rapid Recovery RX is NOT responsible for any medication you take that’s not prescribed by surgeon or physician or over the counter medication, and that it is your choice ?

Yes
No

Do you agree that Rapid Recovery RX is not responsible for any hotel or Airbnb rules? *

Yes
No

Do you agree that Rapid Recovery RX is not responsible for any parking charges and/or fees associated with your recovery care? *

Yes
No

Do you agree that deposits are non refundable no exceptions. *

Yes
No

Do you understand and agree that if your surgery center is out of driving distance for transportation that you are responsible for your own transportation? Approval is required if you’re not within 10 miles of your surgery center. *

Yes
No

Do you agree to allow transportation service and meal prep chef access to your medical form for your health information and information about surgery? *

Yes
No

Do you understand that if you file a dispute for services that I provided is considered fraud and I will have you penalized? * *

Yes
No

Terms & Conditions *

I have read and agree to the terms below*

Your 24 hours starts at your original surgery time given to us as we are on call from that time
forward. Rapid Recovery RX is not responsible for any medication taken without consent from
your surgeon or physician. Rapid Recovery RX is not responsible for the Airbnb rules or the rules
at the hotel you choose. Rapid Recovery RX is not responsible for any transportation that is not
agreed upon booking.

Client Full Name *

Address

Address Line 1

City

State

Zip Code

Date Of Birth *

Phone *

Email *

Please click Next to complete and sign the form online. Thankyou.

Date Of Surgery *

Surgeon Name/ Surgical Facility *

Emergency Contact *

Recovery Care Package Requested *

Additional Services Requested (Extra Transportation etc.) *

Care Recipient Full Name *

Signature *

Draw to sign your signature*