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 Family House team will contact you within 24 hours of your request to discuss eligibility and room availability. This is not a room confirmation. The Family House team will then contact you the day of your request between 11am and 12pm to inform you about room availability.

Complete the form below or call 855-6-FAMILY and ask to speak with the Social Worker or Manager on Duty. You may also email with any non-urgent questions.

See Frequently Asked Questions for more details. Read Family House rules and policies here.
The Family House can assist in helping to find alternative lodging facilities that may provide discounted daily rates if a room is not available. We encourage you to make other lodging arrangements whenever possible as we cannot guarantee a room will be available.

1. Stay Request

* Stay Location

* Arrival Date

* Estimated Departure Date

* # Occupants First Night

2. Patient Information

* First Name

Middle Name

* Last Name

* Gender

* Date of Birth

* Diagnosis

* Facility Treated At

* Inpatient - Hospitalized

* Reason for Appointment

* Will you need any of the following duirng your stay?

ADA Room

Refridgerator (Medication/Breast Milk Only)

Translator

None

* Patient Status

Recipient

Living Donor

3. Guest Information

* First Name

Middle Name

* Last Name

* Gender

Date of Birth

* Relationship to Patient

* Email

Home Phone

* Mobile Phone

* Country

* Street 1

Street 2

* City

*State/Province

* Zip/Postal Code

County

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4. Additional Information

* Have you stayed with us before?

Yes

No

* Do you Live More Than 25 Miles from the Family House

Yes

No

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