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HOUSE OF EVE – HOSPITAL SIGNING INTAKE FORM

Mobile Notary • Apostille Facilitator • Weekend & Late-Night Specialist

(714) 856-1377 • eve@houseofeve.org • www.houseofeve.org

CLIENT INFORMATION

Full Name:*

Phone Number: *

Email Address:*

Are you the signer?*

Yes

No Relationship to signer (if no):

SIGNER INFORMATION (PATIENT)

Patient Full Legal Name:*

Date of Birth:*

Month

Day

Year

Hospital / Facility Name:*

Facility Address:*

Room / Unit / Floor:*

Primary Facility Contact (if known):

DOCUMENT DETAILS

Document(s) Requiring Notarization:*

Does the patient have valid ID available?*

Yes

Not sure

Is the patient alert, oriented, and able to sign knowingly and willingly?*

Yes

Unsure

Special circumstances (mobility, sedation, interpreter, etc.):*

APPOINTMENT DETAILS

Preferred Date:*

Preferred Time Window:

Time

:HoursMinutes

Is this urgent or same-day?*

Yes

Will a witness be present if required? *

Yes

Not sure

CONTACT FOR UPDATES (If different from client)

Name:*

Phone:*

Email:*

PAYMENT TERMS

Add your text

Payment is due in FULL upon appointment confirmation.

Appointments are not booked or held until payment has been received.

Preferred Payment Method:

DISCLOSURE / NO-REFUND POLICY

All payments are non-refundable.
If the patient refuses to sign, becomes medically unable, unconscious, or sedated at the time of notarization, NO refund will be issued.
Facility access delays or restrictions are outside the notary’s control.

Client Initials:

CONFIRMATION

I certify that all information provided is accurate and I agree to the payment terms and no-refund policy.

Signature:

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Date:

House of Eve

(714)856-1377

Eve@houseofeve.org

Accessibility Statement

Terms & Conditions

Refund Policy

Email*

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