Elevé Surgical Concierge

Client Intake Form

Thank you for choosing Elevé Surgical Concierge.

This form helps us better understand your upcoming procedure, recovery goals, support system, and preparation needs so we can provide a personalized concierge experience.

Please complete all sections to the best of your ability.

Elevé provides supportive, educational, organizational, and concierge support services only. Elevé does not replace your licensed surgical team. Please do not use this form for urgent concerns, medical symptoms, complications, medication questions, or emergency needs.

Client Information

Emergency Contact

Surgical Information

Will you be traveling for surgery? *

Recovery Support

Will this person be with you for the first 24–72 hours after surgery? *
Do you have a backup support person? *

Household Information

Who lives in your home? *
Do you have responsibilities involving: *

Employment Information

Current Occupation *

Preparation Assessment

How prepared do you currently feel for surgery? *

Support Assessment

What do you feel least prepared for? *

Recovery Environment

Will you be recovering: *

Client Goals

Communication Preferences

Best time to reach you *
Preferred method of communication *

Additional Information

Scope Acknowledgment

Please do not use this form for urgent concerns, medical questions, symptoms, complications, or emergencies. Contact your surgeon, licensed healthcare provider, or emergency services as appropriate.