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

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?*


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.