Returning Families Reservations

First visit families must have their reservation made by their NIH Social Worker.

For returning families, you may fill out the form below and press Submit to make your reservation. You will receive a call from The Inn a few days before your reservation date to confirm.

* required information
Returning Family Reservations Form 
Patient Information
First Name:*
Last Name:*
Inn Arrival Date:
(mm/dd/yyyy)
Anticipated Time of Arrival:
First Appointment Date:
(mm/dd/yyyy)
Expected Departure Date:
(mm/dd/yyyy)
Phone:*
Business Phone:
Cell Phone:
Name of Medical Team Contact:
Medical Team Contact Phone Number:
Name of person(s) accompanying:
Relationship of accompanying person(s):
Date of Birth of accompanying person (if under 18):
Email Address of accompanying person(s):
Is the patient taking medication?:
Yes
No
Will the medication need refrigeration?:
Yes
No
Is this visit for:
Active Treatment
Intensive care, surgery or crisis
Is the patient:
An in-patient (staying overnight at the Clinical Center)
An out-patient (staying overnight at the Inn)
Is the patient or any others in a wheelchair?:
Yes
No
Prefer:
Tub w/shower
Handicapped accessible shower
No preference
Are there any special needs for any family member?:
Yes
No
If yes, please explain:

Note: Due to the fragile health of many of our residents, we kindly request that you contact your medical team to reschedule your visit or make alternative housing accommodations if anyone traveling with you is experiencing cold, flu or stomach flu symptons or has been exposed to chicken pox.

This form is for returning families only.

        

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