Online Guest Stay Request

GUEST REQUEST TO STAY ONLINE FORM

Complete your online request and click on SUBMIT.

Introduction optional - ALWAYS TOP

1. Stay Request

* Stay Location

* Arrival Date (customize)

* Estimated Departure Date (customize)

* # Occupants First Night

* English spoken at Home

* Region (mandatory - customize)

* Priority (mandatory - customize)

* Source List (mandatory - customize)

Request completed by

* Hospital Staff (mandatory - customize)

* Social Worker (mandatory - customize)

* Social Worker First Name (mandatory - custpmize)

* Social Worker Last Name (mandatory-customize)

* Social Worker Email (mandatory - customize)

* Social Worker Phone (mandatory - customize)

2. Patient Information

2.1 Please notice on this form Patient Middle Name is required. If no Middle Name, please enter NA.

* First Name

* Middle Name

* Last Name

* Gender

* Date of Birth

* Ethnicity

* Diagnosis

* Facility Treated At

* Is patient hospitalized?

Type of Email

Phone

Phone Type

Type of Address

Country

Street 1

Street 2

City

State/Province

Zip/Postal Code

County

2.3 Patient COVID Information

* Vaccination Status

* Vaccine Name

* # Vaccinations

* Country

* First Vaccination Date

* Second Vaccination Date

* Booster Vaccination Date

* Exemption Note

* Vaccination Note

* Cond L1 Patient

Patient UDF01

Patient UDF02

Patient UDF03

Patient UDF04

Patient UDF05

2.2 Add Another Patient

4. Guest Information

4.1 Please notice on this form Guest Middle Name is required. If no Middle Name, please enter NA.

* 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

6. Vehicle Information (mandatory - customize)

* Vehicle License

* Vehicle Model

* Vehicle Make

* Vehicle Color

4.3 Guest COVID Information

* Vaccination Status

* Vaccine Name

* # Vaccinations

* Country

* First Vaccination Date

*Second Vaccination Date

* Booster Vaccination Date

* Exemption Note

* Vaccination Note

* Cond Guest UDF 01

4.2 Add Another Guest

7. Additional Information (Stay UDFs)

Stay UDFs content ... optional


ss

* Cond Stay L1

* 4a. Do you give RMHS permission to use any photos, artwork, or videos taken/created including the first name, age, and diagnosis of our child.

* Social

8. Notes regarding this request:

9. Acceptance ALVAYS LAST

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

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GUEST REQUEST TO STAY ONLINE FORM

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