Sharing Wishes Request

Patient Details

If none, please type in your Memorial email address.

Address

City

State

Zip Code

First Name

Middle Name

Last Name

Email Address

Nursing Home Name (if applicable)

Primary phone

Date of Birth

Caregiver Details

If none, please type in your Memorial email address.

Address

City

State

Zip Code

Relationship to Patient

Is caregiver POA for patient

Primary phone

Requestor Information

Date of application submission

Address

City

State

Zip Code

Hospice Staff Name

Hospice Staff Title

Hospice Agency Name

Cell phone

Hospice Staff Email

Wish Information

Describe the proposed wish in detail.

Why this wish is important to the patient.

List any special considerations/precautions to consider in granting this wish.

Include any urgency and/or timeframe needs for granting this wish in regard to the patient's medical condition.

Wish Expenses

List all expenses anticipated to grant this wish. Total expenses must not exceed $599.00. List the item(s), the company from which to purchase and expense of each item.

Wish Consent Checklist

I have spoken with the patient and/or POA regarding this Sharing Wishes request.

I have received verbal permission from the patient and/or POA for representatives of Memorial's Sharing Wishes Fund to discuss this request with outside parties, including vendors, so that the wish may be setup, scheduled and granted.

I have documented this verbal permission accordingly in the patient's chart.

I have requested and secured permission from the patient and/or POA for photography regarding this Sharing Wishes request.

I have had the patient and/or POA sign the consent form for photography, interviews, etc. so that this wish may be used for public relations purposes.