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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

Contact information

Full Name:*

Phone Number:*

Email Address:*

Signer (Inmate) Information

Inmate Full Legal Name:*

Booking Number / ID*

Date of Birth:*

Month

Day

Year

Housing Location (Facility, Module, Tier, Cell):*

Relationship to Inmate:*

FACILITY DETAILS

Facility Name:*

Facility Phone (if known):

Facility Address*

DOCUMENT DETAILS

Document(s) Requiring Notarization:*

Does the inmate have valid ID available?*

Yes

NO

Not sure

If NO, alternative verification available?

Yes

NO

Not sure

Special instructions or important details

APPOINTMENT DETAILS

Preferred Date:*

Preferred Time Window:*

Is this urgent or same-day? *

Yes

NO

CONTACT FOR UPDATES (If different from client)

Name:

Phone:

Email:

PAYMENT TERMS

Payment is due in FULL upon appointment confirmation.

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

Preferred Payment Method:

DISCLOSURE / NO-REFUND POLICY

If the inmate refuses to sign, is unavailable, or does not appear at the time of notarization, NO refund will be issued.
Facility delays, lockdowns, or access restrictions are outside the notary’s control.

Payment Policy

Payments are non-refundable. We understand that circumstances may change, and when appropriate, we may offer a service credit toward a future appointment, reviewed on a case-by-case basis.

Credits have no cash value, are non-transferable, and do not guarantee availability

Client Initials:*

“Please type your initials to confirm you have read and agree to the disclosure.”

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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“Full Name (serves as electronic signature)”

Date:*

CLIENT INFORMATION

Full Name:*

Phone Number: *

Email Address:*

Are you the signer?*

Yes

No

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

No

Not sure

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

Yes

No

Unsure

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

APPOINTMENT DETAILS

Preferred Date:*

Preferred Time Window:

Time

:HoursMinutes

Is this urgent or same-day?*

Yes

No

Will a witness be present if required? *

Yes

No

Not sure

CONTACT FOR UPDATES (If different from client)

Name:*

Phone:*

Email:*

PAYMENT TERMS

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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: