Hospital Intake Form

Hospital Name

City & State

Contact Name & Title

Email Address

Phone

How do you think the lollipop tree will be beneficial to your hospital and patients? How do you think the lollipop tree will be beneficial to your hospital and patients?

On average how many children with cancer are you treating on a monthly basis? On average how many children with cancer are you treating on a monthly basis?

Digital Signature (please type your name)

Date