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Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

First Name

Email Address

Last Name

Date of Birth

Do you have a Terminal Medical condition and are seeking Hospice Care? *

No

Yes

Are you currently suffering from a medical condition, illness, and want more information about Hospice or Palliative Care? *

No

Yes

If you answered yes to any question, please elaborate

Diagnosis (optional)

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

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Covid Compliant

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Contact:713-947-2277

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AFFINITY HOSPICE & PALLIATIVE CARE

Our company:

Med-Care Health Options, Inc.

dba Affinity Home Health Care

dba Affinity Hospice Prn

201 Enterprise Ave Ste 600C

League City, TX 77573

T: 713.947.2277

F: 713.947.2292

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