Medical Form

This form is to be filled out only by a medical professional on the applicant's care team. Acceptable members of one's medical team include, but are not limited to: physicians, nurse navigators, primary care physicians, social workers, nurse practitioners, etc.

Medical professionals: If you have questions while filling out the application, please refer to our FAQs, or contact us directly at info@aweekaway.org

Please make sure all required fields are filled and items such as a phone numbers, emails, etc. are correct.

Medical Professional Information

Medical Professional Name*


Medical Professional Title*


Organization Name*


Organization Address*




Contact Information*




Patient Information

Patient Name*


Patient Date of Birth*




Medical Information

What is the patient's official diagnosis?*


What is the date of the patient's official diagnosis?*


Please describe the patient's most recent surgery or treatment.*


Does the patient require any special accommodations or nursing care?*

Special Accommodations Explanation.*


Does the patient have any physical limitations?*

Physical Limitations Explanation.*




Respite Information

How does the patient's medical condition affect their ability to travel?*


How did you find out about A Week Away?*


Signature*

Upon completion of this application you will receive an email to request a letter on business letterhead giving a brief explanation why you feel this patient will benefit from a week away. Please ensure that the patient's full name and date of birth is on the letter.