Hospice Care Family Meeting Request

Hospice Care Family Meeting Request — Form Fields

This healthcare template includes 12 fields. Request form for families to schedule care team meetings about hospice patient plans. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Patient ID (text, required)
• Primary Contact Name (text, required)
• Relationship to Patient (dropdown selection, required) — options: Spouse, Adult Child, Parent, Sibling, Legal Guardian, Power of Attorney, Other
• Contact Email (email, required)
• Contact Phone (text, required)
• Meeting Purpose (dropdown selection, required) — options: Initial Care Plan Discussion, Care Plan Update, Symptom Management Concerns, Medication Review, Comfort Measures Discussion, Bereavement Support, Discharge Planning
• Family Members Attending (checkboxes, optional) — options: Spouse, Son, Daughter, Sibling, Grandchild, Religious Leader, Attorney, Friend
• Preferred Meeting Format (dropdown selection, required) — options: In-Person at Facility, In-Person at Home, Video Call, Phone Call
• Preferred Day (dropdown selection, required) — options: Monday, Tuesday, Wednesday, Thursday, Friday
• Preferred Time (dropdown selection, required) — options: Morning (9-11am), Midday (11am-1pm), Afternoon (1-3pm), Late Afternoon (3-5pm)
• Specific Topics or Questions to Address (long text, required)