My Portal : Celebration Church

Hospital Visitation

*Which Campus Do You Attend:
What is your relationship to the Patient?
*The Patient is My...:
PATIENT INFORMATION
*Patient's First Name:
*Patient's Last Name:
*Patient's Age:
*Which Campus Does Patient Attend:
Has patient requested visit or agreed to receive a visit? (Patient must consent to the visit):
*Agrees:
FACILITY INFORMATION
*Hospital Name:
*Date Admitted:
*Room Number:
*Reason for Hospitalization:
Additional Information: