Guests - Demo 1

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

Upto 5 guests and 4 patients.

New: Limit arrival date and expected departure date!

1. Stay Request

Include any instructions or considerations, as desired.

* Stay Location

* Arrival (max 90 days from today)

* Departure (max 60 days from arrival)

* # Occupants First Night

English spoken at Home

Region

* Priority

* How did you hear about us:

Request completed by

Staff

Social Worker

2. Patient Information

Include any instructions or considerations, as desired.

* First Name

Middle Name

* Last Name

Gender

Date of Birth

Ethnicity

Diagnosis

Facility Treated At

* Will patient be hospitalized?

Patient MultiSel UDF

Does patient have private insurance?

Does Patient Have Medicaid?

Has patient been exposed to any contagious disease?

Yes

No

Add Another Patient

3. Guest Information

Include any instructions or considerations, as desired.

* First Name

Middle Name

* Last Name

Gender

Date of Birth

* Relationship to Patient

Contact Information

* Email

Type of Email

Home Phone

* Mobile Phone

By providing your mobile number, please 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 this number

Type of Address

* Country

* Street 1

Street 2

* City

*State/Province

* Zip/Postal Code

County

Vehicle Information for all guests (if applicable)

Guest MultiSel UDF

Need a parking space while staying with us?

Another Phone 2

Other Guest Information

Add Another Guest

4. Additional Stay Information

Distance from Hpuse

0 - 49

50 - 149

150+ Miles

Stay MultiSel DD UDF

Select Type of Insurance

Medical Assistance / Number

Private Insurance / Group #

Language Interpreter

Needed Language

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

Notes regarding this request:

Acceptance

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

Navigation

Guest Stay Request

Navigation