Online Registration

* Pediatric Patient

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

* Patient Ethnicity

* Location of Patient

*

Patient Room #:

* Parent or Guardian First and Last Name

* Date of Birth (MM/DD/YYYY)

* Relationship to patient

* 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

* Email:

Second Guardian/Caregiver Name (First and Last)

* Date of Birth (MM/DD/YYYY)

* Relationship to patient

* Primary Phone Number

I agree to receive texts at this number.

(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: