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?
* 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?