RMHC Richmond Request a Room Form

The Request a Room form must be completed and submitted by a medical
professional at the hospital serving the patient.

If you have any questions, please call 804.355.6517.

Stay Information

Today's Date *
Date of Arrival *
Length of Stay *Indicate days, weeks, or months

Number of Guests

Adult Guests *
Children Guests *

Patient Information

Patient Name *
DOB (Must be 21 or younger) *
Gender *
MaleFemale

Hospital Medical Info

Referring Unit *
Hospital *
Diagnosis *
Physician *
Referring Staff Member Name & Title *
Staff Phone Number *
Staff Email *

Primary Guest Information

Parent/Guardian Name *
Phone Number *
Relationship to Patient *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Other Parent/Guardian Name
Phone Number
Relationship to Patient

Additional Guest Information

Guest #1

Name
Age
Relationship to Patient

Guest #2

Name
Age
Relationship to Patient

Guest #3

Name
Age
Relationship to Patient

Accommodations

Does the family have their own form of transportation? *
Do any guests have physical limitations that would prevent them from climbing stairs? *

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