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Hospice Residence Forms

Referrals to our Bethell Hospice Residence Care Program can be made either by the individual seeking service or by a medical services provider.

PLEASE NOTE, the online forms are currently not working. If you wish to submit a Residence Referral Form, or Residence Admission Agreement Form, please contact Amita Patel or Dorothy Rankin, Intake Coordinators at 905-838-3534, ext. 2240, or intake@bethellhospice.org

Messages sent via the internet can be intercepted. If you are concerned about providing your personal information by email or website form submission, please contact us directly at 905-838-3534 to arrange for an alternate method of communication.

For more information, please refer to our Bethell Hospice Privacy Statement.

Residence Referral Form

Once your Residence Referral Form has been accepted, both the Consent Service Agreement for the Hospice Residence Program and the Bethell Hospice Foundation Form will need to be completed. See below.

CONSENT SERVICE AGREEEMENT Hospice Residence Program

Form 1 of 2. Please also complete the next form, Resident/Community Client Consent for Bethell Hospice Foundation below.

RESIDENT/COMMUNITY CLIENT CONSENT for Bethell Hospice Foundation

Form 2 of 2.

For more information, or should you require assistance in completing a form, please contact Amita Patel or Dorothy Rankin, Intake Coordinators at 905.838.3534 ext. 2240 or email at intake@bethellhospice.org . Thank you.

Thanks to our Funders