Thank you for considering Amity Care Hospice services in caring for your loved one.  We recognize how challenging it can be to make a call such as this.  We want you to know that we are honored by your request and will do our best to provide the love and compassion that you want for your loved one.  You can reach us by calling 678.402.5235.  Your call is important to us and, in order to assist you, it would be helpful if you could have the following information handy:

• Your name
• Your relationship to the person who needs assistance
• The best time to contact you
• Your most pressing concerns or needs whether it be:

1. Pain and/or symptom management
2. Help with medication
3. Help in understanding the illness
4. Assistance with self-care (bathing, dressing, eating, etc.)
5. Support for family
6. Making decisions about care options
7. Help with coping emotionally or any other concerns
8. Location of the person needing assistance
9. Their physician’s name and phone number.

If you wish, you can also email that information to our Clinical Director, Valerie Tapper, RN, BSN, CHPN, at vtapper@amitycarehospice.com.

Again, we welcome the opportunity to serve you and those you love.  In the midst of this transitional time, we wish you peace.

First Name *

Last Name *

Phone Number *

What is your relationship to the person who needs assistance? *

Self Spouse Family Member Friend Other

What is the best time of day to contact you?

What are your most pressing concerns or needs?
(Please check all that apply)

	Pain and/or symptom management		Support for family
	Help with medication		Making decisions about care options
	Help in understanding the illness		Help with coping emotionally
	Assistance with self care (bathing,dressing, eating, etc.)		Other

What is the current location of the person needing assistance?

At home In the hospital In a nursing nome In an assisted living home Other

Current Doctor Information

Dr’s First Name

Dr’s Last Name

Dr’s Phone

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