Request Assistance

Gastroparesis Support Services Inc. (GSSI) helps gastroparesis patients traveling to Louisville for care with hotel stays, food/grocery cards, local rides, and gift bags. Assistance is based on available funds and is not guaranteed. Please complete this form and we will contact you. Your information is kept private and is only used to arrange your assistance.

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Patient & Contact — Full name *

Date of birth (MM/DD/YYYY) *

Home street address *

City *

State *

ZIP *

County

Cell phone *

Email *

Preferred contact methodCallTextEmail

Emergency contact name *

Emergency contact relationship

Emergency contact phone *

Appointment Verification — Gastroparesis diagnosis confirmed? *

• Yes
• No

Clinic *— Select Choice —University of Louisville GI Motility ClinicVanguard Surgical

Treating doctor name

Appointment date (MM/DD/YYYY) *

Appointment time

Type of visit/testing/procedure

Referring doctor name/practice

Appointment Verification — Clinic contact permission *

• I give GSSI permission to contact my clinic to verify my appointment.

If you cannot upload your appointment confirmation here, GSSI will contact you for it.

Travel Details — Arrival date (MM/DD/YYYY) *

Travel Details — Departure date (MM/DD/YYYY) *

How are you traveling?

• Driving
• Flying
• Other

Flight information (if flying)

Are you traveling with a companion/caregiver?

• Yes
• No

Companion name

Companion relationship

Companion phone

Have you received GSSI help before?

• Yes
• No

If yes, when?

Assistance Requested — Assistance requested

• Hotel stay
• Food/grocery card
• Local rides
• Gift bag/other support

Hotel — Check-in date (MM/DD/YYYY)

date Wheelchair-accessible or

Hotel — Check-out date (MM/DD/YYYY)

Hotel — Number of guests

Hotel — Bed type preference

Hotel — Accessible room or other room needs

Food/Grocery — Number of people traveling

Food/Grocery — Dietary needs

• Liquid diet
• Low-fat/low-fiber
• Tube feeding/TPN
• Other

Food/Grocery — Food allergies

Rides — Pickup address

Rides — Drop-off address

Rides — Ride dates/times needed

Rides — Wheelchair-accessible vehicle needed?

• Yes
• No

Gift Bag/Other — Anything specific you need for your stay or testing prep

About Your Need — Briefly tell us why help is needed for this trip *

Household size at home

Are you receiving help for this trip from another organization, church, or fundraiser?

• Yes
• No

If yes, who?

About Your Need — Attestation *

• I attest the information in this form is true, and I understand assistance is based on available funds and is not guaranteed.

Special Needs — Mobility needs

Special Needs — Service animal

• Yes
• No

Special Needs — Oxygen or medical equipment

Special Needs — Food allergies / other allergies

Special Needs — Room preference

• Non-smoking
• Smoking

Special Needs — Early check-in or late checkout needed due to test prep?

• Yes
• No

Special Needs — Language or communication needs

Consents — Information use *

• I understand GSSI will store and use my information only to arrange assistance, as described above.

Consents — Appointment changes *

• I agree to notify GSSI if my appointment is cancelled or changes.

Consents — Story/photo use (optional)

• GSSI may use my story and/or photo for social media and fundraising.

Consents — Feedback follow-up (optional)

• GSSI may follow up with me for feedback or a testimonial.

Grant Reporting (Optional) — Age range

Optional. Used only in anonymous totals for grants, never with your name.

Grant Reporting (Optional) — Gender

Grant Reporting (Optional) — Race/ethnicity

Grant Reporting (Optional) — Veteran status

• Yes
• No

Grant Reporting (Optional) — Insurance status

• Insured
• Underinsured
• Uninsured

Signature — Type your full name (acts as signature) *

Date (MM/DD/YYYY) *

Submit