Referral Form | Quantum House

*Date family would like to check in: mm/dd/yyyy

*Check out Date: mm/dd/yyyy

*Department or Dr. Referred By:

*Are you a new family to Quantum House: YesNo

Patient Information

*First Name:

*Last Name:

*Birth Date: mm/dd/yyyy

*Gender: MaleFemale

*Expected Length of Stay:

*Diagnosis:

Guest Information

*First Name:

*Last Name:

*Relationship to Patient:

*Address:

*Suite/Apt:

*City:

*State:

*Zip:

*Email Address:

*Home Phone:

*Cell Phone:

*Emergency Phone:

*Employer:

*Car Make/Model/Color: Vehicle that will be parked at Quantum House

Additional Guest Information

*Guest Name:

*Guest Age:

*Guest Name:

*Guest Age:

*Guest Name:

*Guest Age:

Release Information

Primary Guest, please read and check off each item in the release.

*I accept responsibility for any damages caused to Quantum House or its contents by me, a member of my family, or my guest.:

*I understand that I enter Quantum House at my own risk and that Quantum House is not responsible for my possessions and/or personal injury to me, a member of my family or my guests. Failure to abide by Quantum House Rules and Regulations will result in my being asked to vacate Quantum House and the forfeiture of my privilege to stay at Quantum House in the future.:

*Alcohol and/or illegal drugs & smoking are NOT permitted in Quantum House or on the campus at any time.:

*I authorize the release of the following: Video Recording, Audio Recording, Photographs/Slides & Multimedia taken at Quantum House or at St. Mary’s Hospital by a Quantum House Staff member or myself. I grant this consent voluntarily and I understand that I will not be paid a fee for any of the above.:

*I understand that Quantum House does not provide maid service and I am responsible for cleaning my guest suite weekly. I will be expected to thoroughly dust, vacuum & clean my entire guest suite including wash my own linens on a weekly basis. At check out – I am expected to clean the room back to the condition it was in at check in with the exception of the beds and towels. All dirty linens should be left in the assigned laundry basket and dropped off in the laundry room. An inspection of your room will take place before you check out.:

*There is a $35.00 per night, per room, guest fee to be paid weekly. There is a $20.00 key deposit due at check in.:

*Electronic Guest Signature: Please enter your initials

*Date:

*Please leave this field empty:

Quantum House

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