Terri's Legacy Project
Medical Professional Contact Sheet

Name  __________________________________________________________

Address __________________________________________________________

City/State/Zip ____________________________________________________

Telephone numbers: office ____________________  cell __________________

Email address _______________________________________________

Profession: (Please circle all that apply)

Medical Doctor     Registered Nurse    Nurse Practitioner     Physicians' Assistant        

Social Worker      Administrator      Chaplain     Psychiatrist     Psychologist        

Professor of Medicine     other _____________________

Specialty ________________________________________________________

States in which licensed to practice ______________________________________

Hospital with which associated _____________________________________________

Willing to review medical records in selected cases to give professional opinion on need for and likely efficacy of life-preserving treatment, nutrition or hydration?
Yes      No       (Please circle one.)

Willing to consider, when authorized, conducting an independent medical examination in order to give such an opinion?
Yes      No       (Please circle one.)

Willing to consider accepting transfer of a patient who is being denied life-preserving treatment, nutrition or hydration?
Yes      No       (Please circle one.)

Please return completed forms to: Terri's Legacy Project, c/o Joleigh Little, 11228 S. Balsam Ave., Solon Springs, WI 54873 or email information to joleigh@centurytel.net.  This list will be maintained on an ongoing basis by the Terri Schindler Schiavo Foundation.