Boston Children's Hospital


A. Reservation Request Information
Wednesday, August 21, 2019 * Will this be your first stay? Yes   No
* Date of Check-in: Pop Calendar * Date of Check-out: Pop Calendar
  Applications without a check-out date cannot be processed.
Special needs or considerations for stay: (i.e. home care needs, wheelchair access, pack 'n play, etc.)
Social Worker/Case Manager/Referred by: (if applicable)

B. Patient Information
* Patient Last Name: * Patient First Name:
* Gender: Male  Female  Unknown * Date of Birth (or Due Date): Pop Calendar
* Street Address: Primary Language:
* City: * State: Interpreter Needed: Yes  No
* Country: * Zip Code:  
Home Phone: Cell Phone:
E-mail Address:

C. Medical Information
In-Patient - Admission Date(s):


Out-Patient - Appointment Date(s):
Diagnosis:
Medical Record Number:
Treating Department: (i.e. Cardiology, Allergy, etc.)

D. Guest Information: Please include all guests that will be staying. Please list patient if they will be staying in house.
We offer one room per family. Rooms accommodate 1-4 people depending on size.
No more than 4 people per room, including the patient.
Guest Name Relationship to Patient Age (list if under 18)
1.
2.
3.
4.
* I acknowledge that no more than 4 people will be staying in the room.

E. Who should we contact regarding this reservation?
* Name: * Phone Number:
* E-mail Address: * Relationship to Patient:


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