RMH STAY REQUEST FORM - qa01master02

GUEST REQUEST TO STAY ONLINE FORM

Complete your online request and click on SUBMIT.

1. Stay Request



2. Patient Information


Doctor
Does patient have private insurance?
Does patient understand English?
Guest Patient UDF
Guest Patient UDF01
Has patient been exposed to any contagious diseases?
Has patient stayed with us before?
Medicaid ID (if no Medicaid, type N/A)
Multiple Selection Horizontal
Please enter the name of the Treating Doctor (optional)
Please specify any contact isolation precautions for the patient or anyone in your family that will be staying at the House
Single Check


3. Guest Information


Contact Information


Guest Occupant UDF
Have you stayed with us before?
Horizontal Single
It is very important that you specify contact isolation precautions for the patient or anyone in your family that will be staying at the House.
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4. Additional Information

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.
4b. Are there any special needs for your family? (wheelchair, etc.)
4c. Guest Stay UDF
4j. Vehicle Single Select (Y/N)
4k. Will you have a vehicle on premises?
Are there any contact isolation precautions for the patient or anyone in your family that will be staying at the House?
Guest Stay UDF A
Guest Stay UDF01
Ordered UDF
Single Check Box
Social

Notes regarding this request:





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