Online Stay Requests

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Guest Request

1. Stay Request Completed By The Family Guest


2. Patient Information


Has patient been exposed to any contagious disease?
Does patient have private insurance?
Name of Treating Doctor
Other Patient Information


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?
Other Guest Information


4. Additional Information

Are there any special needs for your family? (wheelchair, etc.)
Medical Assistance / Number
Medical Assistance / Contact Name
Medical Assistance / Contact Phone
Private Insurance / Contact Phone Number
Private Insurance / Group #
Do you give RMHC permission to use any photos, artwork, or videos taken/created including the first name, age, and diagnosis of our child.
Language Interpreter
Needed Language

Notes regarding this request:



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

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