REFERRAL ADMISSION REQUEST

Edmonton’s first free-standing residential community hospice offers all of Pilgrims Hospice Society’s end-of-life and grief support programs, in addition to 12 residential hospice palliative suites all under the roof of a beautiful new purpose-built building. Please fill out your contact information below and our staff will reach out to you to gather some basic information about the person you are referring including their Alberta Health Care Number and their main contact information.

The main criteria for admission is that your loved one is dealing with a life-threatening progressive illness with an estimated prognosis of 3 months or less. One other criteria for admission is that your loved one is not interested in pursuing any tests or treatments for the sole purpose of lengthening or shortening their life. We are a welcoming, relaxed and family-friendly place that enables meaningful memories during life’s precious last months, weeks and days.

* Required Fields
Referral for Admission Form:
Name of Person Making the Referral*
First Last
Your Email*
Phone*
Name of your Loved One/Client wanting admission:*
First Last
Date of Birth
MM slash DD slash YYYY
Alberta Healthcare Number (PHN)
When is the person you are referring hoping to be admitted?*
- Ready Now
- Ready Soon - In the next 7 days
- Not ready for admission in the next week
Security Check
Name
This field is for validation purposes and should be left unchanged.

REFERRAL ADMISSION REQUEST

Referral for Admission Form: