Reservation Request for JIM’s Suites for Repeat Guests

Guest Name(Required)

First Last

Requested Dates

Please indicate which dates you'd like to stay. Minimum stay is 2 nights. Check in is between 2:00pm-3:30pm and check out is between 9:30am-11:00am. Alternate times may be available for an additional cost. The check in/out processes will take about 30 minutes to complete, as we want to make sure we have all of the information we need to ensure a wonderful guest experience.

Check In Date(Required)

Do you require early check in (before 2:30pm) for an additional $24 fee?

Check Out Date(Required)

Do you require late check out (after 11:00am) for an additional $24 fee?

Caregiver Contact Information

Who will be the primary contact person during the guest's stay?

Name of Primary Contact(Required)

First Last

Phone Number(s)(Required)

Email(Required)

Relationship to Guest(Required)

Please indicate if the Primary Contact Person is:(Required)

POA (Power of Attorney)

Substitute Decision Maker (SDM)

None of the above

Permissions

Permission to Submit(Required)

Acclaim Health is committed to individual privacy and has taken reasonable precautions to ensure the security of the information you are submitting through this online form. By clicking "I agree" you are acknowledging and accepting the potential risks inherent in submitting personal information and/or personal health information online. Please contact us by telephone at 905-827-8800 if you do not wish to submit this information online and we will be happy to assist you.

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Requested Dates

Caregiver Contact Information

Permissions

Contact us to learn more. 905-827-8800 or 1-800-387-7127

Contact us to learn more.
905-827-8800 or 1-800-387-7127