Guest Preferences

If you are planning a stay with us, you can request some amenities that will make your stay more comfortable. Also, providing us with the additional information in the form below will expedite your registration process.

Remember, we invite you to bring your own pillow, or other items to provide a more comfortable experience.

If you have any questions, please call us at:
605-721-4700 or Toll Free at 1-800-818-1890

Date Called:


Person Placing Call:


Source of Information:

Patient:

Other:



Name of Patient:


Name of Support Person:


Where Staying Before Surgery:


Phone:


Surgery Date:


Doctor's Name:


Status Post-op:

Outpatient
Overnight

Number of Nights (if Overnight):



OVERNIGHT PATIENTS

During your stay, would you like us to arrange a visit from your pastor/priest?

Yes
No

If Yes:

Religious Preference:


Church:


Pastor/Priest Name:



PATIENT PREFERENCES

Beverages:


Snack (appropriate to surgery):


Reading Material (magazines, newspapers):


Bedtime Snack (Overnight only):


Movies (Overnight only):


Other Requests or Special Needs:



SUPPORT PERSON PREFERENCES

Beverages:


Snack:


Reading Material (magazines, newspapers):


Bedtime Snack (Overnight only):


Movies (Overnight only):




Other Requests or Special Needs: