Name of Visitor:*

(Please note that we are only allowing 1 visitor at a time, for multiple visitors each visitor must fill out a separate form)

Type of Visit:*
Whom would you like to visit: (Resident Name)*
What is the reason for your visit?*
Since you selected "Legal" Please specify the reason for this visit.*
Have you had any of the following symptoms in the last 14 days?*
Have you had any of the following symptoms in the last 14 days?
  Yes No
Fever (100°F or higher) or chills
Cough
Sore Throat
Shortness of Breath or Difficulty Breathing
Fatigue
Muscle or Body Aches
Headache
New loss of Taste or Smell
Congestion or Runny nose
Nausea or vomiting
Diarrhea
Have you had any contact with someone with a confirmed or suspected diagnosis of COVID-19 in the last 14 days?*
Have you traveled within the last 14 days?*
Have you self quarantined for 14 days upon return as per your local Health Department recomendations?*

Sorry at this point in time, we can not grant access to the facility for a visit. Please request a visit once you have finished the 14 day quarantine period, or your symptoms have cleared up.

In the meantime, feel free to schedule a virtual video call with your loved one by clicking the link below.

https://go.oncehub.com/royalpalms


Please select two dates and time slots that would be optimal for you to visit. Our staff will attempt to accommodate all requests on a first-come, first-served basis. Our Visitation program is guided by CMS & CDPH recommendations and is subject to change based upon prevailing conditions in the facility and/or the local community. *
Please select two dates and time slots that would be optimal for you to visit. Our staff will attempt to accommodate all requests on a first-come, first-served basis. Our Visitation program is guided by CMS & CDPH recommendations and is subject to change based upon prevailing conditions in the facility and/or the local community.
  10AM - 12PM 12PM - 2PM 2PM - 4PM 4PM - 6PM
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Please add any information you would like us to know prior to your visit.
Progress