Request A Room

Please complete the form below. Requests to stay are processed Monday thru Friday, between 8 am and 4 pm.

If you have any questions, call 701-232-3980.

Have You Stayed With Us Before*
Patient Name*
Diagnosis*
Care Facility*
Have you asked your child's doctor's office or social worker at the hospital to send RMHC a referral?*
Referrals should be faxed to: 701-364-1954 and must be requested by a parent.
Patient Date of Birth*
Transportation Needed*
Handicap Accessibility Needed*
Date Room Needed
MM slash DD slash YYYY
Numbers of Adults Staying*
(1) Adult Name*
(First, Middle Last)
(1) Adult Date of Birth*
(Day, Month, Year)
(2) Adult Name*
(First, Middle Last)
(2) Adult Date of Birth*
(Day, Month, Year)
(3) Adult Name*
(First, Middle Last)
(3) Adult Date of Birth*
(Day, Month, Year)
(4) Adult Name*
(First, Middle Last)
(4) Adult Date of Birth*
(Day, Month, Year)
(5) Adult Name*
(First, Middle Last)
(5) Adult Date of Birth*
(Day, Month, Year)
Numbers of Children Staying*
(1) Child's Name*
(First, Last)
(1) Child's Date of Birth*
(Day, Month, Year)
(2) Child's Name*
(First, Last)
(2) Child's Date of Birth*
(Day, Month, Year)
(3) Child's Name*
(First, Last)
(3) Child's Date of Birth*
(Day, Month, Year)
(4) Child's Name*
(First, Last)
(4) Child's Date of Birth*
(Day, Month, Year)
(5) Child's Name*
(First, Last)
(5) Child's Date of Birth*
(Day, Month, Year)
Patient Relationship
Physical Address*
Street Address Address Line 2 City State ZIP Code
Mailing Address
If different from above address

Street Address Address Line 2 City State ZIP Code
Preferred Phone*
Email
Guest Health Screening
Please answer YES or NO to all of the questions below.

Have you had any of the following:
Fever higher than 100.4F (38C) in the past 72 hours?*
- Yes
- No
Vomitting in the past 2 days?*
- Yes
- No
Stiff neck or headache with a fever in the past 2 days?*
- Yes
- No
Diarrhea in the past 2 days?*
- Yes
- No
Current skin lesions that are "weepy" (fluid or pus-filled)?*
- Yes
- No
ANY current skin rash?*
- Yes
- No
Current cold or flu symptoms (runny nose, cough, congestion)?*
- Yes
- No
Exposure to Tuberculosis (TB) in the past 2 months?*
- Yes
- No
Exposure to any of the following within the past 3 weeks:*
- Yes
- No
- Chickenpox
- Measles
- Mumps
- Whooping Cough
CORONAVIRUS RELATED HEALTH QUESTIONS
Do you have a fever, chills, sore throat, cough, new onset of shortness of breath, new onset loss of taste or smell, or new onset muscle pain, or have a pending COVID-19 test because you were having any of these symptoms?*
- Yes
- No
Do you have a pending COVID-19 test without any of the symptoms previously mentioned?*
- Yes
- No
In the last 14 days, have you been exposed to anyone with a lab confirmed COVID-19 test or have you had a COVID-19 positive test results?*
- Yes
- No
Have you been told by a healthcare provider or public health official that you should self-quarantine due to potential COVID-19 exposure?*
- Yes
- No
Permission to Complete a Background Check*
Email
This field is for validation purposes and should be left unchanged.

CORONAVIRUS RELATED HEALTH QUESTIONS