Cleaning Program Application

Cleaning Program Application

Thank you for applying for the Pre to Post Transplant Foundation's Cleaning Program. Any organ transplant recipient residing in the United States is eligible for cleaning services.
Once you complete this form, you will be sent an email with a verification form attached to it. You must print and give that form to one of your transplant providers.

(You can also forward the email to them)
Recipient's Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Contact Person's name if different

First NameLast Name
Contact person's phone number if different
Please enter a valid phone number.
Email where we can contact you*
example@example.com
Address

The residence you are staying in immediately after being discharged must be a personal home, apartment, mobile home, etc. We do not accept hotels, rehab facilities, or communal homes.
Address of home being cleaned *

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Is this your permanent address?*

YesNo
Address where you live permanently

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of bedrooms being cleaned*
How many bathrooms being cleaned*
Please list half baths also. Ex. 2.5
Approximate square footage of home being cleaned *
Don't count garage
How many Pets do you have?*
Have you had a solid organ transplant?*
Eligibility Requirement:

At this time, our cleaning program is exclusively available to solid organ transplant recipients. Applicants who have not received a solid organ transplant are not eligible for this program. While we recognize the need for support across various transplant types, our current resources allow us to focus solely on solid organ transplant recipients. We hope to expand the program in the future to assist a broader range of transplant patients.

Sorry for the inconvience.
Date of transplant*

MonthDayYear
Date
Hospital recipient had their transplant*
Organ transplanted (solid organ transplants only)*
Anticipated discharge date*

MonthDayYear
Date
What is the name of your transplant doctor, transplant social worker, or transplant nurse coordinator?*
Only need 1 contact person. We may be contacting to verify
Please provide their email or phone number below (if known)
How did you hear about us?*
Application submitted by:*
Tipping

As the Pre To Post Transplant Foundation is not present during the cleaning service, we are unable to directly assess its quality. Therefore, our sole request is for patients to consider leaving a gratuity as a token of appreciation if they are satisfied with the service. Please note that tipping is entirely voluntary, although it greatly benefits the cleaning crew. If you have any concerns or are dissatisfied with any aspect of the service, we kindly ask that you contact the foundation promptly so that we can promptly address the issue with the cleaning company.
I understand that the Pre To Post Transplant Foundation does not automatically include a gratuity in the final bill, and I am aware that if I am satisfied with the cleaning service, it is my responsibility to provide a tip directly to the cleaning company.

YesNo
Patient Verification Form

After completing this form, you will receive a verification form via email. Please print this form and provide it to one of your transplant providers, such as your Transplant Surgeon, Transplant Doctor, Transplant Social Worker, or Transplant Nurse Coordinator. Your provider will need to fill out the form and email it back to us at info@pretopost.com. Alternatively, you can forward the email with the attached form directly to your provider. Please note that we cannot send the form to your provider on your behalf. We cannot schedule a service with a cleaning company until we have received the completed form.

The completed form must be submitted directly by the provider and cannot be sent by the patient, caregiver, friend, or any other third party. It must be transmitted from the provider’s official email address and submitted to info@pretopost.org
I understand that I will need to provide the verification form to one of my transplant team providers and after they complete the form they (the provider) must send it back to Pre to Post to be eligible for the Cleaning Program.

YesNo
Should be Empty:

Cleaning Program Application

Once you complete this form, you will be sent an email with a verification form attached to it. You must print and give that form to one of your transplant providers.

Address

Tipping