Request a Room

If you are a transplant patient or family traveling into Philadelphia for transplant-related treatment and would like to request a room for an overnight stay at the Family House, please complete the following information and submit. A representative from Gift of Life Family House will contact you regarding the status of the referral within 24 hours of receipt during normal business hours. If your room request is for anytime within the next 48 hours, do NOT submit a Room Request online, please call our Guest Services Desk at 1-855-6-FAMILY and ask to speak with the Manager on Duty.

Due to the nature of the transplant process a referral is not a reservation and we cannot guarantee a room to a family prior to their requested arrival date.

Guest Self Referral Form - 125.5KB
Self Referral Form

* Required Fields

Patient Name*

Patient DOB*

Patient Status*

Transplant Recipient

Living Donor

Reason for Stay*

	Pre-Transplant Appointment		Transplant Surgery
	Post-Transplant Appointment		Hospitalization
	Other

It Other, Please Explain

If out-patient appointment, please describe appointment date, type, doctor/department seeing, and their primary phone number

Guest Name

Guest Home Address*

Guest Primary Phone*

Guest Email Address*

Relationship to Patient*

Requested Check-in Date*

Anticipated Length of Stay

Special Needs (accessible room, refrigerator, translator)

If additional guests to stay at Family House, please list their name and relationship to the patient

Transplant Hospital*

Transplant Unit*

	Kidney		Liver
	Lungs		Heart
	Pancreas

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

Date*

Patient Name/relationship of legally auth. rep.*

Transplant Resources for Patients & Families

Transplant Resources Map

Identify regional hospitals with organ transplant programs and support groups for transplant recipients and their families.

Organ Transplant Hospitals
Volunteer and Support Groups
Transplant Clinical Trials

Caregiver LifeLine Program

Education for transplant caregivers (phsyical and emotional health, financial and employment issues)
Caregiver Resources, such as local support groups
CaringBridge
Trust Scripts