Request 9 Occupants

Stay Request for Up To 4 Patients and 5 Guests

Request Phone and Address for all guests (disabled by default)

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Guest Stay Requests extended to allow up to 4 patients and 5 guests for a total of 9 Occupants.

Admin can change settings to increase max # patients (0-4), max # guests (1-5) and max # occupants (1-9).

Patient-Guest-Stay UDFs can now be ordered with drag-and-drop simplicity.

Guest Stay Request Log enhanced for easy viewing of Patient/Guest Last Name.

Paperless PDFs enhanced to handle upto 4 Patients, 5 Guests and 9 Occupants

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IMPORTANT: HIDDEN UDFS SET TO A DEFAULT RESERVED VALUE TO SHOW IN PAPERLESS PDFs

1. Stay Request Occupants

* Stay Location

* First date of need

* Estimated Departure Date

* # Occupants First Night

English spoken at Home

Region

Priority

Source List

Request completed by

Staff

* Social Workerz: if not found select the last one and replace first and last

Social Worker First Name

Social Worker Last Name

Social Worker Email (enter if blank/different)

Social Worker Phone (enter if blank/different)

2. Patient Information

* First Name

Middle Name

* Last Name

Gender

Date of Birth

Ethnicity

Diagnosis

* Facility Treated At

* Inpatient - Hospitalized

Email

Type of Email

Home Phone

Mobile Phone

By providing your mobile number, please accept to get text messages from our organization. Message and data rates may apply. Visit our website for terms and privacy information. To stop texting, do not accept.

I accept to receive text messages on this number

Type of Address

Country

Street 1

Street 2

City

State/Province

Zip/Postal Code

County

Does Patient Have Medicaid?

Cond Patient

Add Another Patient

3. Guest Information

* First Name

Middle Name

* Last Name

Gender

Date of Birth

Relationship to Patient

Contact Information

Email

Home Phone

Mobile Phone

Check this box to accept to get text messages from our organization. Message and data rates may apply. Visit our website for terms and privacy information. To stop texting, do not accept.

I accept to receive text messages on my mobile number (editable)

Type of Address

Country

Street 1

Street 2

City

State/Province

Zip/Postal Code

County

Check this box to enter your vehicle information

Cond Guest UDF

Add Another Guest

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.

* Cond Stay

Notes regarding this request:

Acceptance

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

Navigation

Stay Request for Up To 4 Patients and 5 Guests

Request Phone and Address for all guests (disabled by default)

*** * ***

Guest Stay Requests extended to allow up to 4 patients and 5 guests for a total of 9 Occupants.

Admin can change settings to increase max # patients (0-4), max # guests (1-5) and max # occupants (1-9).

Patient-Guest-Stay UDFs can now be ordered with drag-and-drop simplicity.

Guest Stay Request Log enhanced for easy viewing of Patient/Guest Last Name.

Paperless PDFs enhanced to handle upto 4 Patients, 5 Guests and 9 Occupants

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Navigation

Sign In

Navigation

Stay Request for Up To 4 Patients and 5 Guests

Request Phone and Address for all guests (disabled by default)

* * *

Guest Stay Requests extended to allow up to 4 patients and 5 guests for a total of 9 Occupants.

Admin can change settings to increase max # patients (0-4), max # guests (1-5) and max # occupants (1-9).

Patient-Guest-Stay UDFs can now be ordered with drag-and-drop simplicity.

Guest Stay Request Log enhanced for easy viewing of Patient/Guest Last Name.

Paperless PDFs enhanced to handle upto 4 Patients, 5 Guests and 9 Occupants

* * *

Navigation

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