Request a Room Form

PERSONAL INFORMATION OF REQUESTER

Name *

First

Last

Relationship to Patient *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Phone *

Primary Phone Relationship to patient

Secondary/Alternate Phone (other caregiver, emergency contact) *

Secondary Phone Relationship to patient

Email *

Primary Language

Secondary Language

Have you stayed at PRMH before?

PATIENT INFORMATION

Full Name *

Date of Birth *//

Must be 21 years old or younger to stay.

Gender *

Hospital in Philadelphia *

Hospital Department (e.g. Oncology, Cardiology, Neonatology) *

Brief Description of Treatment *

Diagnosis *

Date of First Appointment During Requested Stay *

Check In *

Please call us if you are planning to stay at the House anytime within the next three days. The system will not allow you to make a room request online for this period of time.

Check Out *

Treating Doctor *

Doctor's Phone Number

Hospital Social Worker

Hospital Social Worker's Phone Number

Inpatient/Outpatient *

For Inpatient Only: Will the patient be staying in the House prior to admission? (explain in the Comments section below) *

Have all patients and family members who will be staying at the House been vaccinated for measles, mumps, and rubella (MMR), and been vaccinated for and/or diagnosed with chickenpox in the past? *

Yes
No

If No, please explain in detail: *

Are all individuals requesting to stay at the House vaccinated for COVID-19? *

Yes
No

Does the patient have medical insurance? (Including state run insurance, such as Medicaid, or private) *

Yes
No

Comments

ROOM OCCUPANCY

Please list the names of each room guest and their relationship to the patient. Please note that each room can only accommodate up to 4 individuals.

Guest 1

Guest Name

Guest Date of Birth//

Relationship to Patient

Email (Required if 18 years of age or older)

Guardian?

Guardian?

Guest 2

Guest Name

Guest Date of Birth//

Relationship to Patient

Email (Required if 18 years of age or older)

Guardian? (copy) (copy) (copy) (copy)

Guardian?

Guest 3

Guest Name

Guest Date of Birth//

Relationship to Patient

Email (Required if 18 years of age or older)

Guardian? (copy) (copy) (copy)

Guardian?

Guest 4

Guest Name

Guest Date of Birth//

Relationship to Patient

Email (Required if 18 years of age or older)

Guardian? (copy) (copy)

Guardian?

SPECIAL NEEDS

Checkboxes

Wheelchair Access
Full Bathroom with Tub
Pack 'N' Play

PERSONAL INFORMATION OF REQUESTER

PATIENT INFORMATION

ROOM OCCUPANCY

Guest 1

Guest 2

Guest 3

Guest 4

SPECIAL NEEDS

Quick Links

More Information