Online Guest Stay Request


Guest Stay Request

1. Stay Request

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

If premature, how many weeks gestation was baby?
If Other, please include here
Insurance Provider

3. Guest Information- Who will be staying?

Do not text my mobile number

* Have you had a new skin rash within the last four (4) weeks?
* Annual Income (2021)
* Employment
* Military Base

4. Additional Information

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

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.


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