Online Guest Stay Request

STAY WITH US


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

* Do any of the individuals seeking to utilize RMHC services - have a travel history from abroad within the past 14 days?

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

* Have any of the individuals seeking to utilize RMHC services, knowingly had contact with a traveler who recently visited abroad within the past 14 days?


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.

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



Please use the background screening button for all guest over the age of 18 to complete the application process.

 

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