Name
Address
City, ST Zip
Date:
Dear Healthcare Provider,
I am a person who requires specialized nutritional support to sustain my life. My physician and I are providing the following information to familiarize you with my special needs.
(Pick which of the following statements you wish to include in your letter)
• I have a central venous catheter and/or enteral feeding tube. Maintaining access is critical to my ability to receive my nutrition.
• My physician and I have determined an appropriate regimen for the care of my catheter/tube. This protocol may be different than your standard protocol, but I would appreciate your following the recommendations in this form while I am in your institution, if at all possible.
• If I am able, I would prefer to take care of my own catheter.
• The following person has also been trained to care for my catheter and deliver my nutritional support:
Name: __________________________ Phone: (______) _______ —____________
Please feel free to contact my physician for any questions you may have regarding my care.
Sincerely,
Consumer Signature ___________________
Physician Signature___________________
Consumer Name_______________________ Physician
Name:________________________
Consumer Phone # (_______) ______-_____ Physician Phone #: (_____) ______
- _______