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 Contact Phone Number or Email Address
If you are the patient, please just type "self"
If you know the room number, please include it here.
Date of Surgery/Procedure or Date of Admission to Hospital
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.
May we list the surgery/procedure on our Wednesday night prayer sheet?
Yes, but please only list the date and hospital. Do no list the procedure or ailment.
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