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The Hospital Sitters
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Room Emergency Patient's
Patient's Name
*
Patient's Email
Patient's Home Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
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Kentucky
Louisiana
Maine
Maryland
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Rhode Island
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Utah
Vermont
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Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
I believe my services need to be:
*
Emergency Contact Name
*
Emergency Contact Email
*
Emergency Contact #
*
Alt. Emergency Contact #
Emergency Contact Address same as Patient
Emergency Contact Address Same As Patient
Emergency Contact Address
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Hospital
*
Select Hospital
Emory Saint Joseph's Hospital
Emory Johns Creek Hospital
Emory University Hospital Midtown
Northside Hospital Atlanta
Northside Hospital Cherokee
Piedmont Atlanta Hospital
Wellstar Douglas Hospital
Wellstar Kennestone Hospital
Wellstar North Fulton Medical Center
Room Information
*
I.E. Room Number, Tower, Department, Area
Patient Phone Number
If Available
Select Schedule (Charges per Day)
*
Overnight 7PM to 7AM -
$399.00
Daytime 7AM to 7PM -
$399.00
24 Hours -
$769.00
Test -
$1.00
Service Start Date
*
Number of Days of Service
*
Total Cost
Total
Price:
$0.00
Credit Card
*
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