Dialysis: Insulin: Walker/cane/scooter/wheelchair: Other (please Ventilator: Oxygen: specify): Service animal: Bariatric Bed Other machine dependent: Table 1 Primary and Affiliate/Sister Facilities (See Attachment E) Primary Facility Address (Street, Facility Name County Contact Number City, State, Zip) Affiliate/Sister Facilities (Include specific information in Attachment E.) Address (Street, Facility Name County Contact Number City, State, Zip) Signature Page <Insert Facility Name>
Dialysis: Insulin: Walker/cane/scooter/wheelchair: Ventilator: Oxygen: Other (please specify): Service animal: Bariatric Bed Other machine dependent: Table 1 Primary and Affiliate/Sister Facilities (See Attachment E) Primary Facility Facility Name Address (Street, City, State, Zip) County Contact Number Affiliate/Sister Facilities (Include specific information in Attachment E.) Facility Name Address (Street, City, State, Zip) County Contact Number Signature Page <Insert Facility Name>
Hospital_EOP_Template.docx