Hospital Visitation

Is any sick among you? let him call for the elders of the church; and let them pray over him,
anointing him with oil in the name of the Lord. – James 5:14

We want to be there for you as a Church family as you face challenges in life. Please send us your information through our
Hospital Visit Form below and someone will make contact with you as soon as possible.

Hospital Visitation

Main Contact Person
Name*
Prefix First Last Suffix
Email*
Phone*
Are you a regular attender or member of Goshen?*
- Member
- Regular Attendee
- No
Patient Information
Patient Name*
Prefix First Last Suffix
The Patient is Your:*
(i.e. mother, brother, etc.)
Does the patient currently serve in the church? If so, in which ministry?
Would you like for us to notify the Ministry Leader?
- Yes
- No
Hospital/Nursing Home Name*
Hospital/Nursing Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Hospital Room #*
Date Admitted*
Date Format: MM slash DD slash YYYY
Reason for admittance*
What are the hospital/nursing home visiting hours?*

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Hospital Visitation

Main Contact Person

Patient Information

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