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Intake Form
Hospital and Facility Intake Form
Name of Facility/Hospital
(required)
Your Unit or Floor
(required)
Unit/Floor Direct Phone Number
(required)
Address
(required)
Manager’s Full Name
(required)
Manager’s Email
(required)
Manager’s Direct Phone Number
(required)
Other contacts number and email.
(required)
What is your pay scale for contract Registered Nurse?
(required)
What kind of nurse do you need?
(required)
Type of hospital and how many beds?
(required)
Does the nurse need to float?
(required)
Select one option
Yes
No
Type of Facility and Staff ratio:
(required)
What certifications do you need the nurse to have?
(required)
What are the duties?
(required)
What dates do you need covered?
(required)
What kind of shifts do you need?
Select one option
8 hour shift
12 hour shift
Housing must be provided and be as private as possible. Everything should be present to cover the basic needs. If you have housing available please describe it.
Please provide any other information we may need.
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