Gary's House Guest Referral Form

garys-house-logo.pngGary’s House is safe, comfortable, and affordable home away from home for families of hospitalized patients. All guests must be referred by a hospital or practice representative. Please provide all known information, including best contact number, and a Gary’s House representative will call to discuss availability and schedule appointment for check-in.

If you have any questions, please call 207-535-1320.

Arrival Date


Estimated Nights Reserved


Number in Party


Guest Name, First and Last


Guest's Address


City


State


Zip


County


Additional Guests (Please provide both first and last names)


Guest's Email


Guest's Local or Cell Phone Number


Guest's Car Make and Model


Car Color


Does referred party have a medical necessity to stay with us?


Referral made by (Medical representative's name):


Medical Representative's Title


Medical Representative's Treatment Facility


Medical Representative's Telephone


Medical Representative's Email


Additional comments regarding guest needs or restrictions:


To the best of your knowledge, does any member of the party have a communicable disease?


If so, please explain:


I have reviewed the terms of stay with party and recommend them for stay:

Gary's House Terms of Stay

Thank you for taking every precaution necessary, including frequent hand washing, to avoid spreading illness. Please help us maintain a secure and pleasant environment by respecting the house rules:

  • Guests must register through the Executive Director’s Office at an agreed upon time.
  • Only pre-approved, registered guests are allowed in Gary’s House.
  • Lengths of stay at Gary’s House are variable. A recertification is required at two week intervals.
  • No medical services are permitted at Gary’s House.
  • Any patient must be accompanied by companion prior to and/or following medical visit/treatment.
  • Smoking, illegal drugs, firearms and alcohol are strictly prohibited.
  • Disorderly conduct will not be tolerated.
  • We cannot accommodate pets. Service animals must be disclosed in advance to the Executive Director.
  • We reserve the right to move guests from one room to another.

I have read the rules of Gary’s House and agree to abide by them. I agree to be responsible for the rules compliance of my family and/or other members of my party. I understand that I must take appropriate precautions to protect my valuables and other personal items. I understand that I enter Gary’s House at my own risk and that neither Gary’s House nor Mercy Hospital is responsible for personal injuries. I acknowledge and understand that personal information may be communicated to Gary’s House, if the need arises.