Palliative Care / Hospice Admission Form Template

This Palliative Care / Hospice Admission Form is intended for patients needing comfort-focused care due to terminal or advanced diseases. It captures symptoms, care preferences, advance directives, family involvement, and primary diagnosis—ensuring compassionate and appropriate care planning.

Key Features

• Primary diagnosis & current symptoms

• Advance directives (DNR, living will, POA)

• Preferred place of care (home, hospice, nursing home)

• Family or caregiver involvement

• Medication and allergy documentation

Who Should Use It

Hospice facilities, palliative care units, home healthcare agencies, and chronic illness management teams.