Hospital Notification and Visit Request
If you are a member of Wheeler (or desiring to make notification on behalf of a member) experiencing a health challenge, your Church family is concerned. Please complete the form below to make notification and/or request a visit:
Member/Patient Name:
*
Hospital/Nursing Home Name:
*
Hospital/Nursing Home Location/Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Room Number (if known):
Date of hospitalization (if known):
-
Month
-
Day
Year
Date
Patient's Condition:
*
Please Select
Stable expected to recover soon
Critical/ICU
Referral to Hospice
Surgery Needed/Planned
Unknown
If surgery notification, please indicate scheduled surgery date:
-
Month
-
Day
Year
Date
Patient/Family Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Requester’s Name:
*
Requester’s Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Requester's Email
*
example@example.com
Requester's relationship to the patient
*
Please Select
Self
Family Member
Friend
Family Group Leader
Ministry Leader
Other
If “Other” selected, please share who:
*
Please verify that you are human
*
Submit
Should be Empty: