Medical Referral | Lily's Pad

Medical Referral Form

Medical Professional Referral Form

Lily’s Pad is a hyperclean, indoor play facility for children who are immunocompromised or considered vulnerable to illness due to a medical condition. Our facility is free to any qualifying child and their immediate family. If you have a child that you would like to recommend for play, please fill out the form below.

This form can also be downloaded as a PDF and filled out. Please email the completed form to [email protected] or mail to: 3320 S. Priest Drive Suite 4, Tempe, AZ 85282.

Parent/Guardian Names

Name of Child

Parent Contact Email

Parent Contact Phone Number

Name of Referring Medical Professional

Medical Professional Phone Number

Medical Professional Email

Any Additional Information You Would Like to Provide Us

The child I am referring is immunocompromised or considered vulnerable to illness due to a medical diagnosis.

I confirm that I am a medical professional (i.e. doctor, social worker, child life specialist, etc) and by filling out this form, I am giving consent for communication between myself and Lily's Pad.

Medical Referral Form

Medical Professional Referral Form

Family Resources

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