Intake form
Home
Southern California End of Life Options Consultation
Intake form
Home
Patient name
*
First Name
Last Name
Date of birth
MM
DD
YYYY
Home address (please include the city)
Please include city of residence
Phone number
Email address
Emergency contact name
First Name
Last Name
Emergency contact phone number
Name of person filling out form (if other than patient)
First Name
Last Name
What is your terminal illness and when was it first diagnosed?
Who is your primary physician?
Have your physicians established a prognosis of less than 6 months to live?
Have you discussed your end-of-life wishes with your physicians?
What were their responses?
Have you enrolled in a hospice program?
Name of hospice (if applicable)
Any other information
Thank you!