BACKGROUND IMAGE ADMIN VIEW
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Guest Stay Request
1. Stay Information



2. Patient Information

*
Chevk this box to confirm the information below is required
* 1. Guest Patient 2025
* Cond Patient
*
GUESTpatient99
* Patient MultiSel UDF
* MRN
* Are you Military Family?
* Have you Stayed with us?
* question public
* Does patient have private insurance?
* Patient Last Name
* Have you stayed with us
* Dog Type
* What is Tshirt Size??
* Does Patient Have Medicaid?
* Has patient been exposed to any contagious disease?
* Have you stayed with us
* Name of Treating Doctor
* Other Patient Information
* what is your tshirt size?


3. Guest Information

Contact Information

 I accept to receive text messages on this number
* 1. Guest Occupant 2025
*
By checking this box I understand the following information is required
* Guest MultiSel UDF
* Cond Guest UDF
*
GUESToccup99
* Relig
* Bk Check
* Background Check Date
* Have you stayed with us before?
* Need a parking space while staying with us?
* Another Phone 2
* Other Guest Information


4. Additional Information (Stay UDFs)

* 1. Guest Stay 2025
* Distance from Hpuse
* Stay HTML Text UDF
* Stay Text Area UDF
* Stay Text Box UDF
* Cond Interpreter Language
* Cond Vertical
* Cond Vertical Other
* Cond Stay
*
GUESTstay99
* GSR FORM USED
* Stay MultiSel DD UDF
* Medicaid
* Med #
* Med Name
* Social Worker Phone #
*
Spanish
* T shit size
*
I understand the information below is required
* Select Type of Insurance
*
Please complete the information below according to the type of insurance selected. If you have a combination, complete all.
* Medical Assistance / Number
* Medical Assistance / Contact Name
* Medical Assistance / Contact Phone
* Private Insurance / Group #
* Private Insurance / Contact Phone Number
* Are there any special needs for your family? (wheelchair, etc.)
* Cond 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
*
International
* Type of Pet

Notes regarding this request:





Acceptance

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