BACKGROUND IMAGE ADMIN VIEW
Place this structure plus all content containers or portlets in the first top position of the page grid.

Stay Request for Up To 4 Patients and 5 Guests
1. Stay Request Occupants



2. Patient Information

Does Patient Have Medicaid?
1. Guest Patient 2025
Cond Patient
Patient MultiSel UDF
New Patient UDF1 Currency
New Patient UDF2 Date
GUESTpatient99
New Patient UDF3 HTML
New Patient UDF4 Hyperlink
New Patient UDF5 MSDL
New Patient UDF7 MSVL
New Patient UDF6 MSHL
New Patient UDF8 NUM2D
New Patient UDF9 NUM
New Patient UDF12 SSDL
New Patient UDF10 PASSWD
New Patient UDF11 Single Check
New Patient UDF13 SSHL
New Patient UDF14 SSVL
New Patient UDF15 SSN
New Patient UDF16 TELEFONE
New Patient UDF17 Text Area
New Patient UDF18 Text Box
New Patient UDF19 24HR
New Patient UDF20 24HR
New Patient UDF21 TIME
New Patient UDF22 ZIPCODE
Dog Type
Chevk this box to confirm the information below is required
Have you Stayed with us?
question public
MRN
Are you Military Family?
Have you stayed with us
Patient Last Name
What is Tshirt Size??
Does patient have private insurance?
Has patient been exposed to any contagious disease?
Name of Treating Doctor
Other Patient Information
Have you stayed with us
what is your tshirt size?


3. Guest Information

Contact Information

 I accept to receive text messages on my mobile number (editable)
GUESToccup99
By checking this box I understand the following information is required
Cond Guest UDF
1. Guest Occupant 2025
Relig
Bk Check
Background Check Date
Guest MultiSel UDF
Other Guest Information
Another Phone 2
Have you stayed with us before?
Need a parking space while staying with us?


4. Additional Information

Do you give RMHC permission to use any photos, artwork, or videos taken/created including the first name, age, and diagnosis of our child.
GUESTstay99
* Cond Stay
Interpreter Language
Single Select DDL
Other Text
Guest Stay 2025
Stay HTML Text UDF
Stay Text Area UDF
Stay Text Box UDF
Spanish
Distance from Hpuse
Medicaid
Stay MultiSel DD UDF
GSR FORM USED
T shit size
I understand the information below is required
Social Worker Phone #
Room Type
Are there any special needs for your family? (wheelchair, etc.)
Language Interpreter
Needed Language
Type of Pet
Medical Assistance / Number
Medical Assistance / Contact Phone
Private Insurance / Contact Phone Number
Private Insurance / Group #
Medical Assistance / Contact Name
Select Type of Insurance
International
Please complete the information below according to the type of insurance selected. If you have a combination, complete all.

Notes regarding this request:




Acceptance
Your request will be processed. Do you want to continue?