Hospital / Nursing Home Visit Request

At Lakewood, we strive to share God's love and encouragement with everyone. If a loved one or friend needs someone to visit them in a Houston hospital or nursing home, please use the form below to request that a pastor or caring volunteer stop by to pray with them and share our encouraging support.

Your name *

Email address *

1. Patient Information

Patient Name

Is the patient a member of Lakewood Church? *

(Select Yes or No)

Is the patient a volunteer at Lakewood Church? *

(Select Yes or No)

Is the patient aware of this visitation request? *

(Patient must request or consent to the visit.)

Patient's Age:

Does the patient require Spanish speaking visitors? *

2. Facility Information

Facility Name *

Room Number *

Diagnosis (Hospital Only) *

3. Your Information

Your Name *

(First and Last Name)

Phone Number *

Your relationship to the patient: *

Are you a member of Lakewood Church?

(Please select Yes or No)

Comments:

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