Feel Right At Home Referral - Meals On Wheels
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1MEALS ON WHEELS
2180 Empire Boulevard Webster, NY 14580
Phone (585) 787-8397 Fax (585) 787-9729
FEEL RIGHT AT HOME REFERRAL
The Feel Right at Home meal program helps people transition back to home after a hospital or
rehabilitation stay. We offer two weeks of half-price meals after which participants may choose to end meal
service or continue on the program at a cost based on their monthly incomes.
Patient Information
Male Female
Name
DOB
Address
Home phone
Cell phone
Race African American
American Indian
Asian
Hispanic
White
Primary language (if other than English)
Food allergies
Primary care physician
Diagnosis 1
2
Delivery Information
Option 1: Hot Meals
Days (three-day minimum)
Type
Beverage
Consistency
Monday
Regular
2% milk
Regular
Tuesday
No concentrated sweets
Skim milk
Ground
Wednesday
Low lactose
Lactaid
Thursday
Kosher
Juice
Friday
Option 2: Frozen Meals (one box of 7 frozen meals delivered once per week)
Desired date of first meal
Special instructions or safety concerns
Pets
(pets must be restrained during meal delivery)
Alternate/Emergency Contact Information
Name
Home phone
Work phone
I agree to accept meals ordered and to pay for these meals at the end of each month. I will pay
$3.35 per meal for each meal I receive ($23.45 for a box of seven frozen meals) during the first two
weeks I participate in the program. I may cancel at any time. If I decide to continue on the program after
the first two weeks, I agree to have a diet technician visit me to explain the program and complete an
assessment. My cost per meal may change at that point, depending on my income.
Signature
Date
Referral Source
Name
Phone number
Strong
Highland
RGH
Unity
Other
1/2017
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