Guests - Demo 1

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Guest Stay Request

Include upto 4 patients and 5 guests.
Limit arrival date and expected departure date!

1. Stay Information

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 (source)

Request completed by

Staff

Social Worker

Social Worker New/Other Phone

Social Worker New/Other Email

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?

Are you Military Family?

Have you Stayed with us?

Yes

No

Does patient have private insurance?

Does Patient Have Medicaid?

Has patient been exposed to any contagious disease?

Yes

No

Name of Treating Doctor

Other Patient Information

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

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

Relig

Other Guest Information

Add Another Guest

4. Additional Information (Stay UDFs)

Distance from Hpuse

0 - 49

50 - 149

150+ Miles

I understand the information below is required

Language Interpreter

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

International

Notes regarding this request:

Acceptance

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

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Guest Stay Request

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