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Hospital Visitation Request

Chabad of White Plains offers patient visitation for anyone who could use a friendly visit. A visit from us brings warmth, joy, and connection that can support and assist in the healing process.

If you would like us to visit a family member or friend, you can request it here. We will reach out and coordinate the details.

Please note that the patient must be fully aware of the request. The patient must also agree to the visit. This protects their comfort, privacy, and dignity.

Fill out the form below and we will be in touch soon.
1. Your Information
Full Name*
First Name Last Name
E-mail*
Phone Number*

Area Code Phone Number
Relationship to the Patient

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

2. Patient Information
Full Name*
First Name Last Name
Hospital Facility*
Patients Room Number/Unit *
I confirm that the Patient requested the visit and is fully in agreement to have us visit.

I Affirm the above Statement
Comments
3. Optional Donation
Optional Donation Amount

$360$500$720
Total charge

$0.00

Payment method

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

Should be Empty:

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