Section 1

Full Name*

Email address*

Address*

Phone Numbers

Home

Cell

Section 2

Are you a member of The Mother Church?*
YesNo

Are you a member of a branch church?*
YesNo

Have you had Primary class instruction?*
YesNo

It is Morning Light’s policy for patients receiving Christian Science nursing care to be receiving daily
treatment from a Journal-listed Christian Science practitioner and for the Christian Science nurses to
be in contact with the Christian Science practitioner.

Section 3

Name of Journal-listed CS practitioner giving daily Christian Science treatment*

Phone #*

Email address

City and State of Journal listing*

Alternate Christian Science practitioner, if regular practitioner cannot be reached:

Name*

Phone #*

Section 4

Name of nearest relative*

Relation*
FatherMotherSonDaughterBrotherSisterHusbandWifeGrandfatherGrandmotherCousinUncleAuntNephewNiece

Relative's Address*

Relative's Phone Numbers

Home

Work

Relative's Email address

Section 5 - Health Care power of attorney or legal guardian

please provide copy of health care directive

POA Name*

POA Address*

POA's Phone Numbers

Home

Work

My Health Care power of attorney and/or the following people have permission to participate in discussions about my
health care
YesNo

Section 6 - Person to whom bills should be sent

IMPORTANT NOTE: Morning Light Christian Science Nursing Service is not eligible for either the Medicare or Medicaid program. Insurance coverage is dependent upon individual policies and is the responsibility of the patient and/or family.

Name*

Relation*
FatherMotherSonDaughterBrotherSisterHusbandWifeGrandfatherGrandmotherCousinUncleAuntNephewNiece

Billing Address*

Relative's Phone Numbers

Telephone

Work

Billing Email address

Please indicate your financial arrangements for paying bills*
PersonalFamily FinancesPrivate Insurance

Please read carefully the following declaration so that you understand the conditions for care provided by Morning Light.

• I am an adherent of Christian Science and rely wholly upon God for healing.

• I have read and agree to the STATEMENT OF UNDERSTANDING concerning Christian Science nursing Service provided by Morning Light Foundation.

• I understand it is Morning Light’s policy that an individual receiving Christian Science nursing care has daily treatment from a Journal-listed Christian Science practitioner.

• In the event the Christian Science practitioner of my choice cannot be reached in an emergency, I authorize Morning Light Christian Science Nursing Service to call another Journal-listed Christian Science practitioner to treat me until such time as my regular Christian Science practitioner is again available.

• I agree to cooperate with the proper care that is being given.

• I understand a statement of daily charges will be presented and are due as billed. Questions and financial arrangements should be directed to the Morning Light Administrator / Director of Christian Science Nursing.

• I understand that Morning Light Christian Science Nursing Service is not responsible for my valuables or personal property

STATEMENT OF UNDERSTANDING

I understand that the Christian Science Nursing ministry of Morning Light Foundation, Inc., provides Christian Science nursing services consistent with the attached Christian Science Nurse Scope of Services, dated June 2025, and received from the office of Christian Science Nursing Activities, Boston, MA.

My signature below confirms that I have read the Christian Science Nurse Scope of Services dated June 2025, or had it read to me, and that I understand and agree that this is the care that I will receive while receiving Christian Science Nursing care from Morning Light Christian Science nurses.

Your submission of this form indicates your understanding of these statements and your desire to receive the care described above:

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