The Prepared RN: New Client Request FormPlease use this form to request assistance from The Prepared RN for you or your loved one! Name * First Name Last Name Email * Phone (###) ### #### What services are you interested in? Post ED Follow Up New Diagnosis Medication Management Upcoming Surgery or Procedure Care Coordination Other - See Below: Message * How did you hear about us? Social Media Flyer/Poster Word of Mouth Other Consent & Privacy Acknowledgement * By completing this form, you acknowledge that The Prepared RN strictly adheres to all Patient Privacy Laws and HIPAA regulations. Information shared will be used solely for care coordination, advocacy, and liaison purposes. You will be provided with relevant disclosures and forms to review and sign during the intake process. What The Prepared RN Does * Care Coordination: Scheduling appointments, organizing referrals, and connecting you with vetted providers * Patient Advocacy: Explaining diagnoses, lab results, medications, and care plans in plain language * Education & Guidance: Providing information about common conditions, preventive care, and next steps * Telehealth Guidance: Supporting virtual visits and helping you communicate with your providers * Written Care Plans & Summaries: Optional summaries of conversations, discharge instructions, or care plans * Support During Urgent Situations: Guidance for non-emergent urgent situations and post-ER follow-up What The Prepared RN Does Not Do: - Cannot diagnose, prescribe, or treat medical conditions - Does not replace your doctor, specialist, or other healthcare provider - Cannot provide emergency medical care - call 911 or go to the nearest ER for chest pain, severe injury, or life-threatening symptoms - Cannot provide medications or clinical orders Yes - I acknowledge and consent. Thank you! A member from The Prepared RN team will be in touch with you soon!
