Staying At Gift of Life Family House

Please note that this is not a reservation and we cannot guarantee a room to a family prior to their requested arrival date.

Do you live more that 25 miles away from Family House?*

Yes
No

Have you or another person related to the patient stayed at the Family House before?*

Yes
No

Patient Name*

First Last

Additional Guest(s) Names and Relationship to Patient

Please include first and last names.

Patient's Date of Birth*

MM

DD

YYYY

Patient's Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone*

Primary Email*

Requested Check in Date*

Please note that this is not a reservation and we cannot guarantee a room to a family prior to their requested arrival date.

Requested Check Out Date*

Family House Staff understands that check-out date may change based on a family's needs.

Transplant Hospital*

Transplant Unit*

Heart
Kidney
Liver
Lungs
Pancreas

Reason for Stay*

Patient Status*

Recipient
Living Donor

Which member of your transplant team are you meeting with?*

Appointment Date, for Outpatients*

Appointment Time(s)

Do you need any of the following during your stay?

ADA Room
Refrigerator (for medication or breast milk only)
Translator

Name of Person Completing this Form*

First Last

Release Authorization*

By clicking Yes, I the patient, authorize the release of Protected Health Information to Gift of Life Family House for the purpose of evaluating eligibility for lodging at their facility. I request that the transplant social worker of the transplant hospital or their designated representative disclose and release the above information, and any other information requested by Gift of Life Family House including, but not limited to: treatment dates and ongoing treatment requirements. You are authorized to release this information to the Gift of Life Family House social worker or their designated representative via telephone, facsimile, electronic mail, or standard mail. I understand that: (1) I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization; (2) the information released in response to this authorization may be re-disclosed to other parties; (3) my treatment or payment for my treatment cannot be conditioned on the signing of this authorization.*

Yes, I Agree
No, I Do Not Agree

Today's Date*

Patient's Name or Legally Authorized Representative*

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Guest Information

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