Online Guest Stay Request

GUEST REQUEST TO STAY ONLINE FORM

Complete your online request and click on SUBMIT. - Preserve Center 40%

Guest Stay Request

Add patients email, phone and address (optional)

Add additional guests email, phone, address (optional)

1. Stay Request

New: Add Social Worker if new/changed.

* Stay Location

* Arrival Date

* Departure (max 30 from arrival)

* # Occupants First Night

English spoken at Home

Region

Priority

How Did You Hear About Us?

Request completed by

Staff

Social Worker (leave blank for new or select from list)

Social Worker First Name (enter if blank/different)

Social Worker Last Name (enter if blank/different)

Social Worker Email (enter if blank/different)

Social Worker Phone (enter if blank/different)

3. Guest Information

* First Name

Middle Name

* Last Name

Gender

Date of Birth

Relationship to Patient

Contact Information

Type of Email

Home Phone

Mobile Phone

By providing your mobile number, please accept to get text messages from our organization. Message and data rates may apply. Visit our website for terms and privacy information. To stop texting, do not accept.

I accept to receive text messages on this number

Type of Address

* Country

* Street 1

Street 2

* City

* State/Province

* Zip/Postal Code

*County

	*
Guest Check Occ

Guestoccufield

* Occ Pref

V1 Value

V2 Value

V3 Value

* Payment Date

* Guest Multi Check Occ

Value 1

Value 2

Add Another Guest

4. Additional Information (stay udfs)

	*
Guest Check Stay

* Gpick

* G9

* U2

* Favorite Vacation

* Guest Multi Check Stay

Value X

Value Y

* Optionpref

Emerg. (First, Last)

User1

Notes regarding this request:

Acceptance

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

CONFIG TEMPLATE

This template controls the elements:

FOOTER: Footer Title, Footer Descriptions

* This message is only visible in administrative mode

MyNPO
123 Nonprofit Lane
Give City, State 12345
info@yournpo.org

Testing/Demo Credit Card for AN

Visa 4007000000027
Exp. current date or later
CSV 111

Testing/Demo eCheck with AN

eCheck: John Doe

Checking

Routing 121141754

Acct 7687245428

Max USD100

Testing/Demo Credit Card for IATS

Visa 4222222222222220

Master Card: 5111111111111118

Testing eCheck with IATS (USA)

Routing Number	111111111
Account Number	12345678

$1.00	OK: 678594
$2.00	REJ: 15
$3.00	OK: 678594
$4.00	REJ: 15
$5.00	REJ: 15
$6.00	OK: 678594:X
$7.00	OK: 678594:y
$8.00	OK: 678594:A
$9.00	OK: 678594:Z
$10.00	OK: 678594:N
$15.00	If CVV2 = 1234, the response is OK: 678594:Y. If no CVV2 is entered, the response is REJ: 19
$16.00	REJ: 2
$17.00	REJ: 22
$192.00 (NA Only)	If sent via API (iATSLink or WebService) a) IP is invalid format: Rej: 5. b) IP is valid format: OK: 678594.
All other amounts	REJ: 15
All refund amounts	REJ: 15

For Charges and Refunds testing scenarios:

Amount	Result
Any sale amount*	OK: 678594
Any refund amount*	OK: 678594

GUEST REQUEST TO STAY ONLINE FORM

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Guest Stay Request

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