Online Guest Stay Request - RMHC of Huntington

ROOM REQUEST ONLINE FORM

Complete your online request and click on SUBMIT.

(999) 999-9999?999

Social Workers Only

1. Stay Request

Patient must be 21 years of age or under or a high-risk expectant mother.

Person staying must be 18 years of age or have a parent or legal guardian staying at the RMH with them.

* Stay Location

* Arrival Date

* Estimated Departure Date

* # Occupants First Night

Request completed by

2. Patient Information

If this is a high risk pregnancy, an adult family member or friend must remain with the patient at all times.

* First Name

Middle Name

* Last Name

* Gender

* Date of Birth

* Diagnosis

* Facility Treated At

* 1. Name of Person Making Referral

* 2. Title of person making referral

* 3. Phone number of person making referral

4. Email address of person making referral

* HOSPITAL DEPARTMENT

NEONATAL INTENSIVE CARE UNIT

PEDIATRIC INTENSIVE CARE UNIT

PEDIATRICS UNIT

LABOR & DELIVERY

NEONATAL THERAPEUTIC UNIT

BURN UNIT

INTENSIVE CARE UNIT

SURGICAL INTENSIVE CARE UNIT

OUT PATIENT

In-Patient at River Park Hospital

* Physician

* Refer Agency

Add Another Patient

3. Guest Information

A guest is not eligible for admission if:

He/she has any current pest infestation

He/she is currently under CPS investigation or previously convicted

He/she is currently under investigation or previously convicted of a sexual-related offense

He/she is currently under investigation or previously convicted of a violent offense

If a guest is a carrier of any infectious illness, he/she may not be eligible for admission.

* First Name

Middle Name

* Last Name

* Gender

Date of Birth

* Relationship to Patient

Home Phone

* Mobile Phone

* Country

* Street 1

Street 2

* City

*State/Province

* Zip/Postal Code

County

Vehicle Information

* 1. Is there any reason the guest would not be appropriate for Ronald McDonald House?

YES

* 2. Does the guest have a current Child Protective Services investigation or previous conviction?

YES

* 3. Is the guest a registered sex offender or currently under investigation for a sex-related crime?

YES

* 4. Is the guest under investigation for or previously convicted of a violent offense?

YES

* 5. Does the guest have any current pest infestation? If so, guest is not eligible for admission

YES

* 6. Is the guest a carrier of any infectious illness? If so, guest may not be eligible for admission. Please detail below.

4. Additional Information

* 1. Has the family tested positive for COVID-19?

YES

* 2. Has the family been around anyone with confirmed or suspected COVID-19?

YES

* 6. Does the family agree to wear masks, wash hands frequently, maintain social distancing, submit to temperature checks, and other COVID-19 related requirements?

YES

Notes regarding this request:

Please add any special needs or notes below. Add additional patient or guest information below.

Acceptance

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

<< Back

Return To Home

CONFIG TEMPLATE

This template controls the elements:

FOOTER: Footer Title, Footer Descriptions

* This message is only visible in administrative mode

RMHC of Huntington

1500 17th Street,

Huntington, WV 25701

ROOM REQUEST ONLINE FORM

Navigation