SMC Lux Post-Op Care Division – selectedmedicalconsultants

SMC Luxe Post-Op Care – Service Request Form

Full Name (Patient)

Date of Birth

Phone Number:

Email Address:

Best Way to Contact You: (Call / Text / Email)

Primary Contact (if different from patient)

Primary Contact Phone:

Type of Procedure(s):

Surgery Date:

Surgeon’s Name / Practice:

Surgical Facility / Location:

Surgeon’s Phone number

Expected Discharge Date & Time:

Will you need transportation after surgery? (Yes / No / Not Sure)

Special Instructions from Surgeon (if any):

Service Address (Where care will be provided):

City / State / Zip:

Type of Location: (Home / Hotel / Recovery Home / Other)

Phone location:

Clinical / Medical Support

Personal Care & Support

Home & Lifestyle Support

Requested Start Date for Services:

Will you needRequested End Date (if known): transportation after surgery? (Yes / No / Not Sure)

Preferred Schedule:

How many hours per day do you anticipate needing support?

Allergies (medications, food, latex, etc.):

Mobility Limitations (if any):

Any medical devices or drains? (JP drains, foley, compression garments, etc.)

Emergency Contact Name:

Emergency Contact Phone:

Relationship to Patient:

Preferred Payment Type: (Private Pay / Other – please specify)

Who will be responsible for payment? (Patient / Family / Other)

Note: Final pricing will be confirmed after a review of your requested services, schedule, and care needs.

Is there anything else you would like us to know about your needs, preferences, or recovery plan?

I understand that SMC Luxe Post-Op Care provides non-emergency support and agree to be contacted regarding my service request.