Guest Stay Request

1. Stay Request

2. Patient Information

* Reason for Appointment
* Will you need any of the following duirng your stay?
* Patient Status

3. Guest Information

Contact Information

4. Additional Information

* Have you stayed with us before?
* Do you Live More Than 25 Miles from the Family House
* Have you or another person related to the patient stayed at the Family House before?
* Name of Person Completing this Form

Notes regarding this request:

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.*


This template controls the elements:

FOOTER: Footer Title, Footer Descriptions
CUSTOM MENU: Images and columns into header main menu submenu items

* This message is only visible in administrative mode