TNF Pre-Death Intake Form - The Natural Funeral

Name of Person Contacting The Natural Funeral

Phone

Dying Person's Name

AKA or nicknames - separated by commas

Briefly, what are the current circumstances (hospice care etc, at home, facility?)

Name of hospice if applicable:

How can we help? Please briefly describe Immediate needs:

Let us know a time/times you are available to meet with a Natural Funeral director to create an after-death care plan. Please provide an address and preferred time for meeting?

Current location of dying person:

Type of Location

Other Type of Location

Pacemaker?

Yes
No
Unknown

Primary Care Physician

Hospice Contact

Immediate next of kin who should be included in any planning meeting:

List any good friends you would like to attend the meeting.

Is there a Designated Agent?

Is there a Designated Agent form? Especially important for cremation.

Yes
No
Unknown

Cremation, burial or natural burial wish?

Other TNF services possibly desired at this point:

Name