Online Guest Stay Request

GUEST REQUEST TO STAY ONLINE FORM

Complete your online request and click on SUBMIT.


1. Stay Request


2. Patient Information




* Patient Care Unit


3. Guest Information: PLEASE, PLEASE ADD GUEST EMAIL. THANK YOU!







4. Additional Information: Please provide your NAME & PHONE NUMBER

* Family agrees to allow hospital to share info with RMHC CTX
* Patient has Medicaid
* Referral Contact Name
* Referral Contact Phone #

Notes regarding this request: Provide full name & DOB for other guests




Acceptance

Your request will be processed. 

I confirm the patient family has been informed that some of their information will be shared by the hospital and given to RMHC CTX to secure services during their child's medical treatment.  

I confirm the family has been informed background checks will be conducted on all guests aged 18 and older. 

Do you want to continue?



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