Please Note: this form must be completed by a physician or physician’s office staff, nurse, social worker, care manager, patient advocate,  hospitalist or other appropriate medical professional at Wake Forest Baptist Health, Novant Health, or Hospice &  Palliative CareCenter.

SECU Family House Eligibility Requirements and Information:

• Patient must be 18 years of age or older.
• Patient and caregiver must have a permanent residence outside Forsyth County, NC.
• Patient must be currently receiving treatment at one of the local medical centers.
• All patients staying at SECU Family House as a guest must have a caregiver with them.
• All guests are asked to pay a nightly fee of $40. Payment may be made by cash, check, debit or credit card.
• SECU Family House is a smoke-free environment and does not allow the use of alcohol or illegal drugs on premises. Smoking is allowed in the designated smoking area only.
• We allow one room per patient with up to four people. Rooms feature two queen beds and a private bath