IMD Guest House – Non-Profit Hospitality House for Cancer & Medical Patients Chicago

Please share your story with us by filling out the form below. IMD Guest House shares guest experiences on its website and through internet platforms. We will contact you before sharing your story. Thank you for sharing your story.

First Name *

Last Name *

Email *

Phone Number

State

Zip

Institution or Referral Organization: *

John H. Stroger Jr. Hospital of Cook County
Rush University Medical Center
Road Home Program at Rush
UI Health
UChicago Medicine
Gift of Hope Organ & Tissue Donor Network
Noah's Hope
Hope for Marian
Veterans Administration

Please select type of treament related to your story and experience: *

Cancer
Disease
Neurology
NICU / PICU
Transplant
Veteran

Other

Please share your story and experience below:

Please select your age group:

Under 18 (Your Child)
18-25
26-35
36-45
46-55
56-65
over 65

How did you hear about IMD Guest House?

Hospital
Organization
Doctor/Healthcare Professional
Social Worker
Friend or Family Member
Internet Search
Volunteer
Brochure or Pamphlet
IMD Guest House Board Member
IMD Guest House Associate Board Member
IMD Guest House Staff or Administrative Personnel

Can we share your story and experience? (We will contact you before doing so) *

Yes

Please let us know if you have any questions or concerns:

Date *

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