GENERAL REQUEST - da01train01

GUEST REQUEST TO STAY ONLINE FORM

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

New: Covid-19 Section added to Patients and Guests. Admin can choose to Show/Hide (default hidden).

1. Stay Request

* Stay Location

* Arrival Date

* Estimated Departure Date

* # Occupants First Night

English spoken at Home

Request completed by

Staff

Social Worker

Social Worker Email (enter if blank/different)

Social Worker Phone (enter if blank/different)

2. Patient Information (0-4)

* First Name

Middle Name

* Last Name

* Gender

Date of Birth

Ethnicity

Diagnosis

Facility Treated At

* Inpatient - Hospitalized

COVID-19 Information

Vaccination Status

Vaccine Name

# Vaccinations

Country

First Vaccination Date

Second Vaccination Date

Booster Vaccination Date

Exemption Note

* Vaccination Note

Age Range

Favorite Superhero

Funding

Guestuserfield

NHI

Primary Language

Sector

Add Another Patient

3. Guest Information (1-5)

* 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

Check this box if you plan to bring a car/vehicle

COVID-19 Information

Vaccination Status

Vaccine Name

# Vaccinations

Country

First Vaccination Date

Second Vaccination Date

Booster Vaccination Date

Exemption Note

* Vaccination Note

Guestoccufield

Occ Pref

Add Another Guest

4. Additional Information

Favorite Vacation

Gpick

Optionpref

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

Routing 121141754

Acct: 7687245428 / Type: Checking

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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