Booking Assistance For Staff & Referrers

Your Name (Referrer)*

First Name

Last Name

Your Email*

example@example.com

Your Phone*

Please include your country code ie. +61

Your Role?*

Which organisation do you work for?*

Your State or Territory?*

Who should we contact to make this booking?*

Patient or Guardian First Name*

First Name

and Last Name*

Last Name

Patient or Guardian Email (if applicable)

example@example.com

Patient or Guardian Phone (if applicable)

Please include your country code ie. +61

Patient or Guardian Postcode

Arrival date (or best approximate)*

DayMonthYear

Departure date (or best approximate)*

DayMonthYear

Preferred location*

(Hospital name or suburb/town)

Preferred Property Type*

Preferred Bedding Type*

Is there a preference for a particular property?

Accessibility Requirements*

Do you know if car-parking will be required?*

Is pet friendly accommodation required?*

Is there a budget range per night?*

e.g. $150 - $250

How is the stay being funded?*

Eligible for financial assistance? If so, please list:

Please share any extra information or preferences to assist with your booking

Newsletter

Yes, subscribe me to this newsletter.

Please verify that you are human*

STATIC TAGS

DYNAMIC TAGS

Full name - Hidden for Monday

Patient or Guardian Name - Not used, Legacy replaced by split First Last

First NameLast Name

Newsletter B

Yes, subscribe me to the MediStays newsletter.

Location (postcode and State combined)