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

Guest Stay Request
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?
* 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
* 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?