Contact Us

Loading...

I would like to

Refer your patient to Hospice & Palliative Care Buffalo

Your Name *

Name of Medical Office you Represent

Phone Number *

Patient's First Name *

Patient's Last Name *

Patient's Insurance Plan

Patient's Estimated Prognosis *

Patient's Diagnosis *

Brief Question or Concern *

Update your address with Hospice & Palliative Care Buffalo

First Name *

Last Name *

Email Address *

Phone Number

Address *

City *

State *

Zip Code *

I Would Like To: *

Brief Question or Concern *

Share your story

Full Name *

Address

City

State

Zip Code

Phone Number

Patient Name:

Please provide the name of the care team and/or individual(s) you wish to recognize:

Share a Message...

By clicking Submit, you grant Hospice & Palliative Care Buffalo (HPCB) permission to share your story with the public, on HPCBs website, publication, social media or print materials in part or its entirety. If necessary, we may contact you for additional details. Your contact information will not be shared outside of HPCB.

I agree to sharing my story

Submit a speaker request to Hospice & Palliative Care Buffalo

Name *

Email *

Phone *

Organization/School Name *

Address *

Anticipated Dates *

Type of Speaker *

Desired Topic *

Brief Question or Concern *

Photo Release Form

Name of Person in Photo/Audio/Video *

Please select *

Patient Community Staff

Address *

Phone *

Please select *

Cell Home Work

Email *

Please complete this section if primary caregiver providing authorization signature below

Name *

Relationship to patient *

Address

Phone *

Please select *

Cell Home Work

Email *

Please Sign

Electronic Signature *

Date *

Internal Use ONLY

Event/Occasion

Name of Hospice Staff obtaining authorization

Title

Department

Contact Us

Loading...

I would like to

I would like to

Request help for a loved one or myself from Hospice & Palliative Care Buffalo

Request help for community grief support from Hospice & Palliative Care Buffalo

Refer your patient to Hospice & Palliative Care Buffalo

Essential Care for Children

Become a Volunteer at Hospice & Palliative Care Buffalo

References

Send a general question to Hospice & Palliative Care Buffalo

Update your address with Hospice & Palliative Care Buffalo

Share your story

Submit a speaker request to Hospice & Palliative Care Buffalo

Photo Release Form

Request help for a loved one or myself from Hospice & Palliative Care Buffalo