O powerful Virgin of Lourdes, full of affliction and with tears in our eyes, we fly unto you, Comforter of the afflicted and health of the sick. Placing in you all our confidence, cognizant of the innumerable and wonderful cures made by you not only in Lourdes but all over the world, we humbly prostrate before you in this dreadful hour of distress and sickness and beseech you with all the fervor, faith and devotion of our souls to hear the supplication which we direct to you in favor of this our beloved patient (mention the name)
Since you have worked so many cures among your devotees, do make one more and save this beloved member of our family. Take him (her) from all danger if it will not be an obstacle to his (her) salvation and we solemnly promise you to spend the rest of our lives as good and practical Catholics in thanksgiving for your powerful patronage.
Virgin of Lourdes, pray for us (Hail Mary)
Comforter of the afflicted, pray for us (Hail Mary)
Health of the sick, pray for us (Hail Mary)
Hail, Holy Queen