Online Guest Stay Request

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1. Stay Request


2. Patient Information



Primary Doctor

Secondary Diagnosis



3. Guest Information



Do not text my mobile number


* Have you been vaccinated

* Have you been in close physical contact in the last 14 days with anyone who is known to have confirmed COVID-19, or Anyone who has any symptoms consistent with COVID-19?



4. Additional Information


Notes regarding this request:




Acceptance

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



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