Request 9 Occupants

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

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

*** * ***

1. Stay Request 9

* Stay Location

* First date of need

* Estimated Departure Date

* # Occupants First Night

English spoken at Home

Source List

Request completed by

Staff

Social Worker

2. Patient Information

* First Name

Middle Name

* Last Name

* Gender

Date of Birth

Ethnicity

Diagnosis

* Facility Treated At

* Inpatient - Hospitalized

Does Patient Have Medicaid?

Does patient have private insurance?

Has patient been exposed to any contagious disease?

Yes

No

Name of Treating Doctor

Other Patient Information

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

Another Phone 2

Have you stayed with us before?

Yes

No

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.

Room Type

Are there any special needs for your family? (wheelchair, etc.)

Language Interpreter

Needed Language

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

*** * ***

Navigation