Intake Form: Concierge Client

Concierge Client Intake Questionnaire
Thank you for choosing Glacier Nurse Direct for your custom nursing needs! Below you will find an intake form regarding the type of assistance you are needing. Please complete in it's entirety. An RN will call you upon receiving it to discuss the next step.

*None of your information will be shared with anyone outside of Glacier Nurse Direct without your written permission. Your privacy is important to us.
Type of Services You Are Requesting

Caregiving, Respite, Aide ServicesNursing Services
Indicate your preferred appointment date for an RN Visit or Consult if you would like to set up now

MonthDayYear
Date
Hour MinutesAM/PM Option
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter the best number to reach you at.
Email Address
Emergency Contact

Please list whom we would need to contact in case of an emergency
Contact Name

First NameLast Name
Phone Number of Contact
Relationship to you:

Spouse/Significant OtherFriendFamilyOther
Medical Provider Information
Primary Care Provider
Phone Number of PCP
Please enter a valid phone number.
MEDICAL HISTORY

Please answer the questions below pertaining to your medical history
What is your reason for needing nursing services? Explain below.
Code Status

Full CodeDNRNot sure
Height
Weight
Current Medical Condition(s) Requiring Assistance:
Previous Surgeries or Medical Conditions:
Please list any prescription medications &/or supplements you are taking along with dosage & frequency:
List any food or medication allergies below: (or NKA)
List any assistive devices such as a cane, walker, wheelchair, hearing aids, etc that you use: (or N/A)
Social History

Please complete below
Employment Status:

Working FT or PTRetiredNot workingOther
Who lives with you in your home? Please list your two primary contacts below or N/A if you live alone:
Name

First NameLast Name
Name

First NameLast Name
Do you have pets in your home?

YesNo
Please list any concerns our staff should be aware of when visiting related to your home setting: (or N/A)
We will contact you upon review of your intake form. Is there anything else you would like us to know about your needs? If so, please add below along with the best time of day to be reached & preferred way to be contacted. Thanks, we look forward to working with you.
Glacier Nurse Direct LLP does not bill insurance, Medicaid/Medicare. We are a private nursing service that accepts cash, check, debit, and credit card payments only. Please see our payment & billing policies on our website for further information.
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Concierge Client Intake Questionnaire

Emergency Contact

Medical Provider Information

Social History