Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone Number Names Name a Email *Date of Birth (Mm-Dd-Yy)Date and time of Surgery (Month-Day-Time)Surgeon / Surgery CenterWhich Services would you like to book? *Queen of the Night Package ( 24 Hours of Nursing Care Highly Recommended - Supplies for dressing changes are covered. BBL Chairs, BBL Pillows and Fajas are not covered )Luxe Care Package ( 12 Hours of Nursing Care One-on-One )Premium Post-Op Package ( 8 Hours of Nursing Care One-on-One )Bella Package ( Minimum of 6 Hours Nursing Care One-on-One )Available Add Ons ( As needed per Hour Care )Meal Preparation ( 3 Meals per Day )BBL Chair / PillowIf the boxes do not reflect the services you would like to book, please specify below.Where are you planning to recover? If you are traveling - how long are you in town for? *Do you have a companion that will be with you during your recovery? *YESNOWould you like your supplies to be included in the fee or would you opt to purchase your own supplies? *YESNOHow did you hear about Complete Care Concierge LLC?? *Patient Names *FirstLastWeight (LBS) Selected Value: 30 Height (Feet) Selected Value: 3 Marital Status *MarriedSingleDivorcedSeparatedDo you have Children?YESNONext of Kin Names *FirstLastRelationship with next of Kin *WifeHusbandFatherMotherSonDaughterUncleAuntyCousinNephewNieceGrandpaGrandmaNext of Kin Contact Telephone *I understand and agree that Complete Care Concierge LLC has a policy of a non refundable $300 service booking fees. *I AgreeI declineBy checking the box on the contact form, you agree to the Terms of Use listed here: Communications through our website or via email are not encrypted and are not necessarily secure. Use of the internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use. By checking this box you hereby agree to hold Complete Care Concierge LLC, its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties. Our website uses reCAPTCHA.Submit
