BACKGROUND IMAGE ADMIN VIEW
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Guest Stay Request
1. Stay Information



2. Patient Information

Chevk this box to confirm the information below is required
New Patient UDF1 Currency
New Patient UDF2 Date
New Patient UDF3 HTML
New Patient UDF4 Hyperlink
New Patient UDF5 MSDL
New Patient UDF6 MSHL
New Patient UDF7 MSVL
New Patient UDF8 NUM2D
New Patient UDF9 NUM
New Patient UDF10 PASSWD
New Patient UDF11 Single Check
New Patient UDF12 SSDL
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
Cond Patient
GUESTpatient99


3. Guest Information

Contact Information

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


4. Additional Information (Stay UDFs)

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

Notes regarding this request:





Acceptance

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