General Stay Request Form

GUEST REQUEST TO STAY ONLINE FORM

Complete your online request and click on SUBMIT.

Guest Stay Request

1. Stay Request

2. Patient Information

* First Name

Middle Name

* Last Name

* Gender

Date of Birth

Ethnicity

Diagnosis

Facility Treated At

* Inpatient - Hospitalized

COVID-19 Information

Vaccination Status

Vaccine Name

# Vaccinations

Country

First Vaccination Date

Second Vaccination Date

Booster Vaccination Date

Exemption Note

Vaccination Note

Add Another Patient

3. Guest Information

* First Name

Middle Name

* Last Name

* Gender

Date of Birth

*Relationship to Patient

Contact Information

Type of Email

Home Phone

* Mobile Phone

Type of Address

* Country

* Street 1

Street 2

* City

* State/Province

* Zip/Postal Code

County

Vehicle Information

COVID-19 Information

Vaccination Status

Vaccine Name

# Vaccinations

Country

First Vaccination Date

Second Vaccination Date

Booster Vaccination Date

Exemption Note

Vaccination Note

Add Another Guest

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.

Notes regarding this request:

Acceptance

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

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GUEST REQUEST TO STAY ONLINE FORM

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