Inquiry Form - MARIXA SUITES RECOVERY HOME

Marixa Suites VIP Client Form for Postoperative Treatment at a Five-Star Hotel

Personal Information

Full Name

Date of Birth

GenderMaleFemale

Address

Phone Number

Passport/ID Number

Medical Information

Type of Surgery/Treatment

Date of Surgery/Treatment

Physician/Surgeon's Name

Hospital/Clinic

Pre-existing Medical Conditions

Allergies

Current Medications

Accommodation Preferences

Number of Companions

Preferred Room Type

Names of Companions

Food Preferences

Additional Services

Wellness and Recovery Services Section

1. Physical Therapy

Frequency (Daily, every two days, etc.)DailyEvery two daysWeekly

Other

Duration

2. Massages

Type of Massage

Other

FrequencyDailyEvery two daysWeeklyOther

3. Alternative Therapies

Alternative TherapiesAcupunctureReikiOther

4. Nursing Services

FrequencyDailyEvery two daysWeekly

Duration

5. Medical Consultations

FrequencyDailyEvery two daysWeekly

Required Specialists

Activities and Entertainment

Preferred Activities (e.g., Reading, watching TV)

Entertainment ServicesMoviesMusicPodcastsOther

Excursions and Visits (If permitted and recommended by the doctor)YesNo

Transportation and Logistics

From the Airport/Station

To the Hospital/Clinic

Other Destinations

Preferred Vehicle

Personal AssistanceDriverPersonal AssistantOther

Communication and Technology Fields

Internet AccessWi-FiCableOther

Necessary DevicesLaptopTabletSmartphoneOther

Communication ServicesPhoneVideo CallsEmailOther

Additional Preferences

Preferred Language

Preferred Schedule

Other Specific Requests

Amenities and Other Services

Emergency Contact Information

Emergency Contact Name

Relationship with the Client

Emergency Contact Phone

Emergency Contact Email

Emergency Protocols Clarification

Emergency Protocols Clarification"

"The following emergency protocols will only be implemented in case of emergencies and require your prior consent at the time of booking. These protocols are designed to ensure your safety and well-being during your stay at our hotel."

Emergency Identification

"Initial Assessment: Hotel staff is trained to identify and assess emergency situations. In the case of a medical emergency, staff will immediately contact the designated medical team." "Notification: Your emergency contact will be notified immediately."

Immediate Response

"Medical Team: The hotel has a medical team on duty 24/7. In case of a medical emergency, the team will be alerted and will respond immediately." "First Aid: Hotel staff is trained in first aid and can provide initial assistance until the medical team arrives."

Emergency Transport

Ambulance: In the case of a severe emergency, ambulance transportation to the nearest hospital will be coordinated." "Private Vehicle: If needed, a private vehicle will be used for quick and safe transportation to the hospital."

Hospital Communication

"Coordination: The hotel will maintain constant communication with the hospital to ensure a smooth and quick transition." "Documentation: All relevant medical documentation will be provided to the hospital for efficient treatment."

Post-Emergency Assistance

Medical Follow-up: After the emergency, the hotel's medical team will conduct follow-ups to ensure appropriate care." "Psychological Support: Psychological support will be offered if needed."

Reporting and Documentation

"Incident Records: All emergency incidents will be documented in detail." "Client Report: A complete report will be provided to the client and their emergency contact regarding the incident and actions taken."

Review and Continuous Improvement

"Evaluation: After each emergency, an evaluation will be conducted to identify areas for improvement." "Training: Hotel staff will receive continuous training on emergency protocols to ensure effective response."

"I consent to the implementation of the emergency protocols described above in the event of an emergency during my stay at the hotel. This consent ensures my safety and well-being."Yes