Home
About
Services
Contact

(310) 910 - 8004

Home
About
Services
Contact

Book with Beyond Nursing

- Step 1 of 2

SELECT YOUR PACKAGE(S)

4 hour package - $ 600.00
12 hour package - $ 900.00
luxe 24 hour package - $ 1,500.00
Transportation - $ 99.00

Add Ons

Transportation to Surgical Center (within 10 mi) - $ 99.00
Wound Care Visit - $ 100.00
Shower/ Grooming Visit - $ 100.00

TOTAL

$ 0.00

CLIENT DETAILS

Client Name *

First

Last

Cell Phone Number *

Email *

Date of Birth *

Sex/Gender *

Preferred Pronoun *

Preferred way to contact you *

Call/ voicemail
text/ voice memo
email

Please select ONLY one

Client Current or Previous Occupation *

Marital Status *

Are you visiting from out of State? *

Yes
No

Are you visiting from out of the Country *

Yes
No

If yes, please tell us where you are visiting from

We ask this because we get a lot of clients from all over the world and we like to make sure all of our clients from out of town feel like they have an extended family here while recovering and visiting.

CLIENT HEALTH HISTORY / INFORMATION

Do you have any Allergies to medication or food? *

No
Yes

If yes, please list ALL allergies:

Ex: Penicillin , Shellfish

Are you taking any medication regularly? *

No
Yes

This information is confidential*

If you answered Yes, please list your medication(s)..

This information is confidential* Ex: Asprin, Iron .

Do You Have Any Current or Past Medical Conditions? *

Yes
No

This information is confidential*

If you answered Yes, please list them

This information is confidential*

Have you had a cosmetic procedure before? *

Yes
No

We ask this because from experience we know you may be more nervous if this is your first procedure. This information is confidential*

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name *

First

Last

If there is an emergency, we will immediately contact this person

Contact Number *

Relation to Client *

SURGEON INFORMATION

Surgeon Full Name *

Name of Surgical Facility *

Address of Surgical Facility *

Address Line 1

Address Line 2

City

State

Zip Code

PROCEDURE INFORMATION

Date of Surgery

If Unknown, we MUST know an accurate date at least 10 days before surgery date or booking will be cancelled and a cancellation fee will have to be applied*

Time of Procedure

If Unknown, we MUST know an accurate time at least 10 days before surgery date or booking will be cancelled and a cancellation fee will have to be applied*

Post Operative Location Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

If unknown, Please provide us with an address where you will recover at least 10 days before your procedure or you risk your booking being cancelled and a cancellation fee will have to be applied*

Please Select Your Procedure(s) ..

CHOOSE ALL THAT APPLY *

Breast Augmentation
Breast Lift
Breast Reduction
Face Lift
Forehead Lift
Rhinoplasty
Necklift
Chin Implant
Eyelid Surgery
Abdominiplasty/ Tummy Tuck
Arm Lift
Rib Removal
Cosmetic Reconstructive Surgery *(if selected please write below what area and the surgical plan as explained to you by your surgeon)
Silicone Removal *(if selected please write below which area/ areas will silicone be removed)
Brazilian Butt Lift * (if selected please write below which areas will receive liposuction)
Gluteal / Butt Implant
Liposuction of any area *(if selected please list area/areas you will receive liposuction)
Abdominal Implants
Pectoral Implants
Orchiectomy
Vaginectomy
Gender Affirming Procedure *(if selected, please write below surgical plan as explained to you by your surgeon )
* Select if you do not see your procedure above and please write your procedure below

FINAL STEPS

How Did You Hear About Us? *

Internet/Search Engine
Friend Referal
Social Media
Referral from a Surgeon
Yelp
Other

What Surgeon Referred You?

PAYMENT DETAILS

TOTAL

$ 0.00

Enter Credit / Debit Card Information *

Card

Name on Card

Please Submit VALID PHOTO ID Here *

Click or drag files to this area to upload. You can upload up to 2 files.

please submit a CLEAR picture of the front and back your ID here.

TERMS OF SERVICE

Terms of Service *

I accept the Terms and Conditions below
I agree to Beyond Nursing waiver & release of liability.
I agree to Beyond Nursing cancellation policy.
I have submitted a photo ID

Signature *

Total

$ 0.00