First Visit Families

First visit families must have their reservation made by their NIH Medical Team.

For medical teams, please fill out the form below and click submit. You will receive an email letting you know that the referral was received and processed. The family will also receive a call from The Inn a few days before their reservation date to confirm.

Institute:* Yes, this is a first visit.

Resident (Patient) Information
First Name:*
Middle Initial:
Last Name:*
Date of Birth:* (mm/dd/yyyy)
Gender:* Female   Male  
Address Line 1:*
Address Line 2:
City:*
State:*
ZIP/Postal Code:*
Country:*
Diagnosis:*


Please list all guardians and relationship to patient
Guardian Name:
Guardian Name:
Telephone Number:*
Telephone Number:
Email Address:*
(where confirmation email can be sent)
 
NIH Doctor:* Phone:
Social Worker:* Phone:
Clinic/In-Patient Unit: Phone:
Research Nurse: Phone:
Patient Care Coordinator:* Phone:
Name of person completing form:*

Inn arrival date:* (mm/dd/yyyy)
Inn departure date:* (mm/dd/yyyy)
Expected time of arrival at The Inn:
Note: Residents may come to The Inn no more than 24 hours before FIRST appointment and may stay no more than 24 hours after their final clinic appointment
Yes, this patient is enrolled in a protocol that may require a stay of 120 days or more at The Inn
First clinic appointment date:* (mm/dd/yyyy)

 

Relations accompanying patient:
Name:

Date of Birth:
(under 18)
Name:

Date of Birth:
(under 18)
Name:

Date of Birth:
(under 18)
Name:

Date of Birth:
(under 18)
Name:

Date of Birth:
(under 18)
Name:

Date of Birth:
(under 18)
Yes, the patient (or any family member) is in a wheelchair/ crutches/ special needs
If language is barrier for this family, what arrangements have been made for interpreter on arrival:
Are there any special needs for any family members? If yes please explain:
      

Boy in Classroom