Hospital/Surgery Information
If the person you're telling us about has already been discharged from the hospital, or had an outpatient procedure, please skip the hospital information and go to the information box.
Your Name *
Your answer
Your Contact Phone Number or Email Address
Your answer
Patient's Name *
If you are the patient, please just type "self"
Your answer
What hospital?
If you know the room number, please include it here.
Your answer
Date of Surgery/Procedure or Date of Admission to Hospital
Your answer
Information about the surgery/procedure/ailment *
This information is only shared with the staff unless you give us permission below to share it with other church members.
Your answer
May we list the surgery/procedure on our Wednesday night prayer sheet? *
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