We are only accepting referral forms from case managers, health team clinicians and LNOs at this time.
Referral completed by: Case MgrHospital StaffUnit POCSelf/FamilyOther
Name of Referrer
Date of birth AND age
On orders? FundedPermissiveNot on orders
Has the patient AND Guest(s) come into close contact (within 6 feet) with someone who has a confirmed COVID–19 diagnosis in the past 14 days?
If yes, explain
Does the patient AND Guest(s) have a fever (greater than 100.4 F or 38.0 C) OR symptoms of lower respiratory illness such as cough, shortness of breath, difficulty breathing or sore throat?
If yes, explain
Provide brief description of medical situation
Is care related to a combat injury?
Is this an elective surgery/procedure?
Date/time of appt(s)
Military Treatment Facility/Hospital
Ward: ICU8D6DNICUEmergency RMOut-patientOther
Last 4 of SSN
Branch: ArmyNavyAir ForceMarinesCoast Guard
List everyone staying at the Fisher House. One room per family. Three people max occupancy (four if one is preschool or younger).
Relationship to patient
Do guests have military IDs?
Will guests have transportation while here?
License plate number
Any special needs or considerations? Is ADA room needed?
Expected date and time of arrival
Projected length of nights needed?
Approved or Denied, By: ________________________________________________
Reason for denial OR waitlist status: ______________________________________________________________________________________
Checked In: _________________________ By: ____________________________
Checked Out: _________________________ Room: _________________________
Vehicle Make & Model: _______________________________
Color: _________________________ Plate #: ______________________________