Overnight RN Care Intake

Overnight RN Care Intake Form

Recover safely. Rest peacefully. Let us take the night shift.
We provide compassionate, skilled overnight nursing care for clients post-hospital, post-op, or during high-need transitions.

Are you or your loved one being discharged from the hospital soon — or recovering from surgery or a major illness? Lifeline Home Health offers professional overnight RN care to support your safety, comfort, and healing at home.

We work closely with hospital case managers, discharge planners, and families to plan care before or after you leave the hospital.

Whether you need vital sign monitoring, medication assistance, wound care, or just peace of mind overnight, we’re here to help — even on short notice.

Please complete the form below and our nurse will reach out to coordinate services.

Client and Contact Information

First Name

Last Name

Your Date of Birth

Phone

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Preferred Contact Method

Phone

Text

Discharge or Surgical Details

Have you been discharged yet?

Yes - recently discharged

No - planning discharge

No - this is private overnight help (not from a hospital stay)

Not sure - want to speak with a nurse

Discharge or Surgery Date (actual or expected)

Discharging Hospital (if applicable)

Overnight Care Preferences

When would you like overnight RN care to begin?

Preferred hours (example: 9PM to 6AM or flexible)

What support do you need overnight? (Check all that apply)

Vital sign monitoring

Pain/symptom management.

Medication Administration

Wound Care

Safety checks / Fall prevention

Restorative sleep support.

Reassurance / anxiety reduction

Family/Caregiver Respite

Other (Please specify)

If "Other", please specify below:

Emergency Contact

First Name

Last Name

Emergency Contact Phone Number

Relationship to the client:

Consent & Follow-Up

Do you consent to Lifeline contacting you to follow up?

Yes

Signature

Sign Here

Date

SMS Opt-in

I agree to receive text messages from Lifeline Home Health. I understand message and data rates may apply. I have read and agree to the SMS Consent Policy.