Online Request

* To complete this request, you must have previously stayed at RMHC-KC in the past three years.
Please contact your hospital medical provider or hospital social worker if you need a request completed for a new guest stay.

* I understand that a room may not be available on the date of the requested check-in due to availability. Please call 816.541.8460 on your day of requested check-in.

Yes, I understand.

* The patient receiving evaluation, care and/or treatment is 21 years of age or younger?

* Do any members of the guest party have symptoms related to contagious illnesses?

* Do you or anyone in your guest party currently have an open case and/or are under investigation by law enforcement or any state child protection division for child abuse and/or neglect?

* Are you or anyone in your guest party listed on the National Sex Offender Registry? (Note all guest ID's are scanned upon arrival)

* Have you or anyone in your guest party been convicted of or are currently facing charges for a felony or violent criminal offense?

Patient Information

* Patient Name ( First and Last )

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

* Patient Vaccination Status

* Patient Gender

Primary Language

* Patient Ethnicity

* Does the patient have Medicaid?

Medicaid Branch

Medicaid Id (if no medicaid, type N/A)

Brief description of what patient is being seen for

* Date of first appointment at hospital

* Will the patient be inpatient or outpatient?

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

* Department

* Diagnosis

* Check In Date

* Check Out Date

* Patient is being treated at:

* Physician/Doctor

Family Contact Information

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

Zip

* Guardian/Caregiver Name (First and Last)

* Guardian Middle Name

* Relationship to patient

* Guardian/Caregiver Gender

* Date of Birth (MM/DD/YYYY)

* Guardian 1 Vaccination Status

* Ethnicity

* Email

* Primary Phone Number

* Alternate Phone

Second Guardian/Caregiver Name (First and Last)

Middle Name

Relationship to patient

Guardian/Caregiver Gender

Date of Birth (MM/DD/YYYY)

Guardian 2 Vaccination Status

Ethnicity

Primary Phone Number

Additional Guests

Additional Guests / Family Members: Add Another Guest

Please provide the name and phone number of a relative or friend of the patient's family in the event staff cannot get in touch with the patient’s family.

* Emergency / Additional Contact name

* Emergency / Additional Phone

Additional Information for your stay

Family’s method of transportation to the hospital or our house?

* Will you have a vehicle on premises?

* Car Make/Model/Description

* Car License State

* License Plate#

* Does anyone in the guest party need a wheelchair accessible room?

* Any additional information you would like to add?