Facility Intake Form

Second Bloom repurposes florals after events and delivers them to local hospices, hospitals, and nursing homes to bring comfort and joy to patients, families, and staff. All flowers are freshly re-cut and arranged in small vases, delivered the Sunday following a wedding. We are aiming to get at least 10 small vases of floral per location.

We simply need a few details to make sure delivery goes smoothly and follows your facilitys policies.

Facility Name

Facility Type

Hospice

Hospital

Nursing Home

Other

If other, please explain:

Phone

(###)

###

####

Facility Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Website

http://

Delivery Contact

First Name

Last Name

Phone

(###)

###

####

Title/Role

Delivery Details

Are you able to accept floral deliveries on Sunday afternoons? If no, please specify another preferred time

Preferred Drop-off Location (lobby, nurse’s station, volunteer office, etc.):

Who should deliveries be checked in with upon arrival?

Restrictions or Guidelines

Facility Intake Form

Second Bloom Oklahoma