Patient Eligibility Form

Fremont Regional Hospice

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About Us
- - Fremont Regional Hospice is your only independent, locally based, non-profit Hospice serving Fremont, Custer, Park, Teller, and Western Pueblo counties.
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  - Why Choose Us?
    
    Our staff has a passion for hospice care and treats all of our patients with the utmost respect and care.
    
    Our hospice is governed by a Board of Directors, all of whom are established leaders within our community.
    
    Patients are encouraged use their own doctor.
    
    24 hour phone support
    
    After-hours visits as needed
    
    Expertise in comfort care, pain control and symptom management
    
    Medications related to terminal illness
    
    Volunteer respite care for families and caregivers
    
    Spiritual support by an inter-faith chaplain
    
    Social/emotional support for the patient and caregivers
    
    Bereavement support for families and the community at large
    
    Your community based non-profit hospice.
  - Additional Information
    
    Community Education Programs
    
    DNR Medallions
    
    Grief Bears
    
    Our Team
Contact Us
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Am I Eligible for Hospice Care?

Name

First

Last

Contact

Email

Phone

Preferred Contact Method

Phone

Email

Phone or Email

Where did you hear about Fremont Regional Hospice?

Please check the following statements as they apply to you or your loved one to see if Hospice care is appropriate.

I have started feeling more tired and weak

I experience shortness of breath, even when resting

I spend most of the day in bed or in a chair

I have noticed an increased weight loss in the past six months

I make frequent phone calls to my physician

I take medications to lessen physical pain

I have fallen several times in the past six months

I have made frequent trips to the emergency room in the past six months

I need help from others with important daily activities (Bathing, Dressing, Eating, Cooking, Walking, Getting out of bed)

My doctor has told me my life expectancy is limited

Patient Information

Relation to Patient

Patient Name

Comments or Questions

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FREMONT REGIONAL HOSPICE

1439 Main Street, Canon City, CO. 81212 (map)

P. 719-275-4315 | F. 719-275-8315

Mon-Fri 8:00 am to 4:00 pm | On-call available 24/7

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