1-800-GIV-ISOK.
Link01 Link02 Link03 Link04

GUEST REQUEST TO STAY ONLINE FORM

Complete your online request and click on SUBMIT.

1. Stay Request



2. Patient Information


* Doctor
* Cond L1 Patient
* mt
* ic
* mp
* Vehicle Make
* # of keys
* Emerg. (First, Last)
* Patients Insurance Member ID#
* PDD
* p
* p
* Patients MutiSel DD
* Department UDF
* Guest Patient june 2022
* Medicaid ID (if no Medicaid, type N/A)
* Does patient have private insurance?
* Does patient understand English?
* Has patient stayed with us before?
* 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
* Guest Patient UDF
* Has patient been exposed to any contagious diseases?
* Multiple Selection Horizontal
* Single Check
* Guest Patient UDF01
* Guest Patient Vertical Select
* Guest Patients Checkbox
* Amount
* Adult Count


3. Guest Information

Contact Information

 I accept to receive text messages on this number

* Guest Occupants Checkbox
* Cond Guest UDF 01
* Vehicle Make
* VC
* VM
* VETERAN
* Guests MutiSel DD
* Guest Occupant June 2022
* Amount
* Adult Count
* Guest Occupant UDF
* 1, Guest Single Check Stay 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.
* Meet a Director
* This is a test of the field length in get masters. Get masters has a limit of how many fields. This test will tell us. This is a test of the field length in get masters. Get masters has a limit of how many fields. This test will tell us. This is a test of the field length in get masters. Get masters has a limit of how many fields. This test will tell us. Get masters has a limit of how many fields. This test will tell us.
* Would You Like To Meet Counselor


4. Additional Information (Stay UDFs)

 * 3. Single Check Stay UDF
* Cond Stay L1
* MS
* Vehicle Make:
* VM
* VM
* VC
* RBG
* UDF WF
* VETERAN/FIRST RESPONDER STATUS: Please select from the following if you believe you are part of the classifications below (note: this is not a determining factor in your request to stay):
* HIN
* Stay MutiSel DD
* Guest Stay UDF June 2022
* Adult Count
* Amount
* Guest Stay Add Edit Checkbox
* 4b. Are there any special needs for your family? (wheelchair, etc.)
* 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.
* 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?
* COP
* Guest Stay UDF A
* Guest Stay UDF01
* Ordered UDF
* Signature
* Single Check Box
* Social

Notes regarding this request:


Text to Identify Refresh CAPTCHA



Acceptance

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

<< Back
Return To Home
CONFIG TEMPLATE

This template controls the elements:

FOOTER: Footer Title, Footer Descriptions
CUSTOM MENU: Images and columns into header main menu submenu items

* This message is only visible in administrative mode