Online Guest Stay Request - Gift of Life Howies House

Guest Stay Request

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. Because of the unpredictability of the transplant process and the length of time families may need to stay with us, room availability changes on a daily basis. We are regrettably unable to accommodate all of the referrals we receive. Once a room is requested, a member of the Gift of Life Howie's House team will contact you within 24 hours of your request to discuss eligibility and room availability. This is not a room confirmation. The Gift of Life Howie's House team will then contact you the day before your request to review our Illness Policy and ensure the request is still needed, and then contact you again the day of your requested check-in between 11am and 12pm to inform you about room availability.

Complete the form below or call (267) 546-9800 to placed a request with a staff member. You may also email with any non-urgent questions.

See Frequently Asked Questions for more details. Read Gift of Life Howie's House rules and policies here.

1. Stay Request

* Stay Location

* Arrival Date

* Estimated Departure Date

* # Occupants First Night

3. Guest Information

* First Name

Middle Name

* Last Name

* Gender

Date of Birth

*Relationship to Patient

Contact Information

* Email

*Mobile Phone

* Street 1

Street 2

* City

* State/Province

* Zip/Postal Code

Check this box to enter your vehicle information

* Vehicle Model

* Vehicle Make

* Vehicle Color

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4. Additional Information

* Have you stayed with us before?

Yes

No

* What is the date of the patient's FIRST transplant related appointment? (If hospitalized, please use requested check-in date)

* What is the date of the patient's LAST transplant related appointment? (If hospitalized, please use requested check-in date)

* Do you Live More Than 25 Miles from Gift of Life Howie's House

Yes

No

* Have you or another person related to the patient stayed at Gift of Life Howie's House before?

Yes

No

* Name of Person Completing this Form

Notes regarding this request:

Please add any additional information:

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 authoritzation.*

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Guest Stay Request

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