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Singer Request From
Information about patient to make our singing visit more lovely
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Name of Requestor / Contact Person
Your answer
Patient's Name
Your answer
Patient's Address (where sing will happen)
Your answer
Contact / On site Phone number
Your answer
Referred by
Your answer
Relationship to Patient
Your answer
Best Days to visit
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Best Time to visit
Choose
Mornings
Afternoon
Early Evenings
Scheduling Priority
Urgent
Next Week
Two Weeks
Weekly
Patient's illness (if pertinent)
Your answer
Is Patient aware of their surroundings?
Yes
No
Clear selection
Can they hear at normal speaking volume?
Yes
No
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Do they have a "better" ear?
Left
Right
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Can they see us while sitting around the bed or chair?
Yes
No
Clear selection
Are there any protective pets we need to be careful with?
Your answer
What are their spiritual traditions?
Your answer
Some of our lyrics are about "life beyond death". Would those lyrics be appropriate?
Yes
No
Clear selection
We may mention: God, Lord, Angels, etc. Okay?
Yes
No
Clear selection
Would household, spouse, friends like to be included?
Yes
No
Clear selection
Special directions to their home. And/or gate codes, outside animals, etc.
Your answer
Any other helpful information we should have before arrival?
Your answer
Please include email address and whether best to call or email or text
Your answer
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