Online Guest Stay Request

Guest Stay Request

1. Stay Request

2. Patient Information- Who is going to be the child receiving treatment?

If Other, please include here

Insurance Provider

3. Guest Information- Who will be staying?

* Employment

* Military

4. Additional Information

* Annual Income

Does anyone staying in your room take medication that requires refrigeration?

Enter additional guest information below, Full Name| Date of Birth:

By clicking yes, you verify you understand and agree to the following statements:


The patient receiving evaluation and/or treatment is 21 years of age or younger.

All guests staying at RMH are free of symptoms related to contagious illnesses.

To ensure the safety and security of guests, staff and volunteers, you authorize a background check on all guests 18 and over.

I understand that RMHC-NWFL cannot guarantee my family a room.


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