Request to Stay

Who is completing this application?

Your Name:

*Rooms can be requested up to two days in advance. If there are extenuating circumstances necessitating an earlier request, please call (518) 438-2655.

* Requested Check In Date

Anticipated Check Out Date

PATIENT INFORMATION:

For additional patients, use the Additional Guest Information section below.

* Patient Name ( First and Last )

Patient Gender

* Patient Date of Birth (MM/DD/YYYY)

Patient Ethnicity

* Diagnosis/Reason for Stay

* Diagnosis Category

* Department

* Patient is being treated at:

* Will the patient be inpatient or outpatient?

Inpatient - Hospitalized Outpatient - Non-Hospitalized Both, during this stay.

GUARDIAN INFORMATION:

Please list the primary guardian(s) information below.

* Guardian/Caregiver Name (First and Last)

* Relationship to patient

* Date of Birth (MM/DD/YYYY)

* Primary Phone Number

I agree to receive texts at this number.

* Email

* Primary Language

Second Guardian/Caregiver Name (First and Last)

* Relationship to patient

* Date of Birth (MM/DD/YYYY)

* Primary Phone Number

I agree to receive texts at this number.

* Email

ADDITIONAL GUEST INFORMATION:

Any immediate family members (parents/guardians/caregivers and siblings) of a pediatric patient may be eligible to stay.

Additional Guests / Family Members: * * I agree to receive texts at this number.

Add Another Guest

ADDRESS INFORMATION:

Please list the primary guardian's address below.

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

State/Province

Zip

If different, please list the second guardian's address below.

U.S. / Canadian Postal Code lookup

Country

Address

City/Villa/Town

County/District

State/Province

Zip

ADDITIONAL INFORMATION:

Does the family need an accessible room?

Is there anything else we should know before we reach out?

INITIAL WELLNESS SCREENING:

In the last 48 hours, have you or any other individuals wishing to stay at RMH had any of the following symptoms? Fever, cold symptoms (i.e. congestion, runny nose, or cough), vomiting, diarrhea, skin rash or skin lesions.

In the last 3 weeks, have you or any other individuals wishing to stay at RMH been exposed to any of the following? Head lice, chicken pox, measles, mumps or whooping cough.

In the last 2 months, have you or any other individuals wishing to stay at RMH been exposed to a person newly infected with tuberculosis (TB)?