Healthcare Partner Referral Form

Referrer Information

Referrer First Name

Referrer Last Name

Role/Title (MD/DO, RN, LCWS, MD, Chaplain, CNA, Volunteer Coordinator, etc)

Organization/Unit/Department

Work Email

Direct Phone Number

Enter in your 10 digit phone number without any periods, dashes or spaces.

Preferred Method of Contact

Email

Phone

Text

Patient Eligibility & Consent

Eligibility criteria includes stage IV cancer, ALS, Huntington’s, Parkinson’s, early stage Alzheimer’s, other life-limiting illnesses, and those actively enrolled in hospice.

I confirm that the patient being referred to Amadora meets eligibility criteria.

The patient must be aware of this referral in advance of your submission. I confirm that the patient being referred is aware and consents to the referral.

The patient understands that the purpose of the referral is to record a life-story video with Amadora.

The patient consents for Amadora to contact him/her or a chosen family member directly to initiate next steps in the filming process.

Patient Information

Patient's First Name

Patient's Last Name

Birthday

Month

Day

Year

Current Location of Care

Patient Phone Number

Enter in your 10 digit phone number without any periods, dashes or spaces.

Patient Email Address

Secondary Contact - Family Member

Secondary Contact - Family Member First Name

Secondary Contact - Family Member Last Name

Relationship to Patient

Secondary Contact - Family Member Phone Number

Enter in your 10 digit phone number without any periods, dashes or spaces.

Secondary Contact - Family Member Email

Please indicate who should be the primary contact for scheduling:

Patient

Secondary Contact - Family Member

Timing & Urgency (Urgency Level)

Please choose one

Urgent (filming requested to be done <7 days from time of referral)

Standard (filming can take place >7+ days from time of referral)

Preferred Recording Location

Filming can take place in the participant’s own home, at one of our Share Your Story events, or in a facility setting.

Will the filming need to take place in a facility such as a hospice house or the hospital?

Yes

No

Healthcare Partner Referral Form

Referrer Information

Patient Eligibility & Consent

Patient Information

Secondary Contact - Family Member

Timing & Urgency (Urgency Level)

Preferred Recording Location

How did you hear about Amadora Legacy Project