Personal Information Form

Personal Information Form

No one at Hospice Yukon will release information regarding your use of Hospice services without your written permission. In situations where our staff or volunteer assesses a potential danger to yourself or others or suspicion of current child abuse or medical emergency Hospice Yukon is required to notify the appropriate authorities; we must also comply with court-ordered release of information.

First Name *

Last Name *

Phone

Email Address

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Date of BirthDate of Birth

Month

Day

Year

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Emergency Contact Relationship0 / 20

IndigenousCollecting confidential data about our clients' culture may help us serve you better. Do you identify as Indigenous?YesNo

Cultural IdentityYou are welcome to share the name of your cultural heritage, First Nation, country of origin, etc:

EmailsWould you like to receive emails regarding Hospice Yukon programs and events? (you can unsubscribe at any time)YesNo

Preferred Appointment RemindersText reminderPhone reminderEmail reminder

Parent/Guardian First NameWhere applicable for permission

Parent/Guardian Last NameWhere applicable for permission