Intake form — Southern California End of Life Options Consultation

Patient name

First Name

Last Name

Date of birth

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