Online Registration

* Patient Name ( First and Last )

* Patient Date of Birth (MM/DD/YYYY)

* Patient Ethnicity

* Location of Patient

*

Patient Room #:

* Parent or Guardian First and Last Name

* Relationship to patient

* Date of Birth (MM/DD/YYYY)

* Primary Phone Number

I agree to receive texts at this number.

* Email:

Second Guardian/Caregiver Name (First and Last)

* Relationship to patient

* Date of Birth (MM/DD/YYYY)

* Primary Phone Number

I agree to receive texts at this number.

Home Address

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

State/Province

Zip

(Please note that your personal information will not be shared with any other organization. By providing your email, you may receive updates from RMHC)

Additional Guests / Family Members: * *

Add Another Guest

*

Within the last week has anyone in your party had a fever, nausea, vomiting, or diarrhea not cause by treatment?

If yes, please explain:

*

Do you wish to accept personal calls while staying at RMH?

* Annual Household Income: