Patient Information To add additional patients, enter the information in the Additional Guests / Family Members section below and select the ‘patient’ relationship.
Patient Name ( First and Last )
*
Patient Date of Birth (MM/DD/YYYY)
For Fetal Care patients, please put the child’s expected date of delivery
*
Patient Gender
Male
Female
Nonconforming
Nonbinary
Unborn
Declined
*
Diagnosis (If unknown, enter in reason for visit: testing, trauma etc)
*
Reason For Stay
Cancer - Cáncer
Chronic Conditions - Afecciones crónicas
Complications at birth - Complicaciones al nacer
Diagnostic testing - Pruebas diagnósticas
Eating Disorders - Trastornos de la alimentación
Heart Conditions - Afecciones del Corazón
Illness - Enfermedad
Injury/Trauma - Herida/Trauma
Mental Health - La Salud Mental
Rehabilitation - Rehabilitación
Surgery - CirugÃa
*
Department
Burn Center
Cardiology
CDRC
CF clinic
Child and Adolescent Psychiatry
Dentistry
Developmental and Behavioral
Ear Nose and Throat
Eating Disorder Clinic
Emergency Department
Endocrinology
Eye Clinic
Family Birthing Center
Fetal Care Center
Gastroenterology
Genetics
Hematology
Inpatient
Intensive Care Unit
Nephrology (kidney)
Neurosurgery
NICU- Newborn Intensive Care
Occupational Therapy and Physical Therapy
Oncology
Orthopedic
Outpatient Clinic
Pediatric Surgery
PICU- Pediatric Intensive Care Unit
Psychiatric
Rehabilitation
Sleep Disorder
Speech Pathology
Surgery
Urology
Other
*
Social Worker/Care Management: (To add a new person, choose "Other")
Please select a response
N/A
Lesley Srikantaiah
Whitney A
Hannah Acock
Marissa Addison
Pia Alabastro
Tara Albury
Melissa Allen
Jamie Andelson
Kelsey Anderson
Laurel Antonucci
Sue Aranki
Whitney Assistant
Jessica Austin
Katie Azarow
Monte Bainbridge
Steven Balshem
Chris Barnes
Laurel Barnes
Shannon Bart
Alex Bass
Karla Bonneville
Shannon Boreson
Johanna Borkan
Lucy Bosche
Nancy Boyle
Kim Brewster
Marie Brice
Heather Bristol
Natalie Brown
Marissa Brynteson
Kristine Bush
Jessica Busse
Julian Caballero
Kyle Cahoon
Kristina Callahan
Melissa Calnon
Riley Carroll
Mike Charles
Kirsten Chavez
Cat Christ
Whitney Cma
Physicians Corrigan
Emily Crocker
Sunshine Crone
Jackson Cutler
Rachel Delance
Mariah Delepierre
Maureen DeLongis
Miranda Delosangeles
Miranda Delosangeles
Kim Dent
Michelle Desai
Gabriela Dovey
Niki Dowdell
Melissa Duncan
Anna Eager
Miranda Ericksen
Shanti Ersson
Leeann Farestrand
Stephanie Fortt
Jill Gaines
Sherrill Gandsey
Raenah Gehm
Katherine Gentry
Michael Genung
Erin Gerber
Piera Glahn
Jessica Glasmann
Paula Glesne
Jan Goodwin
Cindy Griffin
Vanessa Guerrero
Nicole Guice
Raechal Halter
Ryan Hart
Emily Haug
Jennifer Hawkins
Julia Hays
Kristina Headrick
Theresa Heidt-Vanderschoot
Emily Helmold
Dr. Lisa Herzig
Lindsey Holzworth
Thea Hosford
Carla Jackson
Rose Jade
Wendy Jensen
Devon Jero
Kelly Jeske
Jessica Johnson
Amy Johnston, R.N.
Randy Joiner
Regina Joshi-McGaw
Shay Kalberg
Anne Karsian
Shari Kerr
Odhs Kesling
Troy Kindy
Erin King
Kara Klinkebiel
Mollie Knapp
Kristin Knight
Kelly Kociemba
Tami Koder
Ashlyn Koenig
Susanne Kositzin
Kimberly Kraus
Joan Laguzza
Kristy Laird
Kelsey Lawrence
Charles Lewis
Melissa Lloyd
Lisa Maddocks
Joby Mahto
Beverly Martinez
Elizabeth Marx
Kristin Mason
Keren McCord
Shauna McDonough
Joanna McLeod
Mike Mihalis
Cara Miller-Eitel
Andrea Mittleider
Michelle Molony
Natalie Monk
Devon Morefeild
Devon Morefield
Holly Morrow
Maggie Morrow
Michelle Morse
Abby Msw
Meaghan Murphy
Shalene Murphy
Jeff Myerwicz
Katie Nadalsky
Donna Neely
Jennifer Newman
Zoe Orcutt
Jenyka Paguia
Wendy Palmrose
Sarah Parnell
Catherine Patterson
Sandy-Metropolitian Pediatrics
Giuliana Pena
Alex Perez
Lindsey Persinger
Rachel Peters
Jeanie Petersen
Huong Phan
Ryce Pierzina
Terry Platner
Sarah Porter
Heidi Pressly
Stacie Prettiman
Jessica Rae
Kat Rausch
Darcy Reeves
Theresa Reiter
Anne Remsen
Alison Revling
Lydia Reyes
Dburroughs Rn
Clancy Roberts
Linda Robson
Abbie Rohloff
Katherine Rozelle
Karyn Sandhu
Cathryn Sause
David Schmitt
Meredith Schweppe
Sheila Scrobogna
Rachel Seibert
Megan Sergi
John Sheridan
Melisa Sibley
Melissa Sibley
Julia Simas
Whitney Simmons
Coralyn Simons
Mary Smith
Tee Solani
Emily Somervel
Linda Specialist
Ashley St. Clair
Jennifer Stevens
Nancy Stewart
Hanna Stonelake
Cat Stroud
Matthew Sutton
Anna Tajchman
Pamela Thearle
Casey Trieschmann
Stefanie Trissel
Andrea Trusty
Dan Turano
Tim Victorella
Tami Vitauskas
Gina Volonte
Alana Wauters
Michael Wenndorf
Mike Wenndorf
Stacie Westbrook
Jeannette Whalen
Jake Wicks
Lori Widener
Cynthia Wightman
Zadora Williams
Rebecca Witherow
Katie Woods
Madeline Woods
Lindsay Wooster
Angee Wright
Nadia Yang
Other
Physician/Doctor
*
Patient is being treated at:
Bend Surgery Center
Bend Urology Assoc.
Bluefish Dental
BMC- Summit Medical Group
Cascade surgery center
Cascadia Family Dental
Casey Eye Institute
Central Oregon Pediatric Associates (COPA)
Central Oregon Speech & Language
Childrens Heart Center of Central Oregon
Deschutes Pediatric Dentistry
Embark Behavioral Health
High Lakes Health Care
Kartini Clinic
Legacy Emanuel/Randall Children's Hospital
Mosaic
Northwest Gastroenterology Clinic/Randall
OHSU/Doernbecher Children's Hospital
Partners in Care
Pediatric Cardiology Center of Oregon/Randall
Providence St. Vincent Medical Center
Pure Light Family Chiropractic
Sage View Psychiatric Center
Shriners Children's
St Charles Pedal Clinic
St Charles Redmond
St Charles Sleep Center
St. Charles Bend
St. Charles Cancer Center
The Oregon Clinic/Randall
Unity Center for Behavioral Health
Weeks Family Medicine
Other
*
Will the patient be inpatient or outpatient?
Inpatient - Hospitalized
  Outpatient - Non-Hospitalized
  Both, during this stay.
Oregon Health Plan OHP Medicaid Information While Ronald McDonald House Ronald McDonald House does not charge a fee or ask families to pay for their stay, we do work closely with state Medicaid (Oregon Health Plan OHP, Washington, Alaska, and Idaho State Medicaid) to obtain lodging reimbursement for a family's stay. This funding helps Ronald McDonald House ensure families can stay at no cost. If the patient is still in utero, the parent's Medicaid information can be entered in.
*
OHP ID Number (If no OHP/Medicaid-Type in N/A, If you do not know your Medicaid ID-Type in Unknown))
*
Medicaid Coordinated Care Organization/Transportation Brokerage (If no Medicaid, choose "No Medicaid")
WA Medicaid - Apple Health
Umpqua Health Alliance
Advanced Health
Jackson Care Connect
All Care CCO
Cascade Health Alliance
Columbia Pacific CCO
Central Oregon Intergovernmental Council
Eastern Oregon CCO
InterCommunity Health Plans CCO
PacificSource Community Solutions
Translink
Trillium Community Health Plan Inc
Yamhill Community Care
Idaho Medicaid
Alaska Medicaid
Open Card
No Medicaid
Guardian Contact Information
*
Guardian/Caregiver Name (First and Last)
*
Guardian/Caregiver Gender
Male
Female
Nonconforming
Nonbinary
Unborn
Declined
*
Date of Birth (MM/DD/YYYY)
*
Relationship to patient
Patient
Mother
Father
Grandparent - Abuelo(a)
Friend of Family - Amigo(a) de la Familia
Sister - Hermana
Brother - Hermano
Step-sibling - Hermanastro(a)
Step-parent - Padrastro/Madrastra
Aunt - Tia
Uncle - Tio
Other - Otro
Foster parent - Padres adoptivos
Parent - Madre/Padre
Sibling - Hermano(a)
*
Primary Phone Number
Do you consent to the guest service team contacting you via text? (message and data rates may apply)
Please select a response
No
Yes
Alternate Phone
*
Email
Second Guardian/Caregiver Name (First and Last)
Guardian/Caregiver Gender
Male
Female
Nonconforming
Nonbinary
Unborn
Declined
Date of Birth (MM/DD/YYYY)
Relationship to patient
Patient
Mother
Father
Grandparent - Abuelo(a)
Friend of Family - Amigo(a) de la Familia
Sister - Hermana
Brother - Hermano
Step-sibling - Hermanastro(a)
Step-parent - Padrastro/Madrastra
Aunt - Tia
Uncle - Tio
Other - Otro
Foster parent - Padres adoptivos
Parent - Madre/Padre
Sibling - Hermano(a)
Primary Phone Number
Do you consent to the guest service team contacting you via text? (message and data rates may apply)
Please select a response
No
Yes
Email
Additional Guests / Family Members
Add Another Guest
*
Primary Language
English
Arabic
Awadhi
Azerbaijani, South
Bengali
Bhojpuri
Burmese
Chinese, Gan
Chinese, Hakka
Chinese, Jinyu
Chinese, Mandarin
Chinese, Min Nan
Chinese, Wu
Chinese, Xiang
Chinese, Yue(Cantonese)
Dutch
French
German
Gujarati
Hausa
Hindi
Italian
Japanese
Javanese
Kannada
Korean
Maithili
Malayalam
Marathi
Oriya
Panjabi, Eastern
Panjabi, Western
Persian (Farsi)
Polish
Portuguese
Romanian
Russian
Serbo-Croatian, Serbian, Coation, Bosnian
Sindhi
Spanish
Sunda
Tamil
Telugu
Thai
Turkish
Ukrainian
Urdu
Vietnamese
Yoruba
Karen
Hungarian
ASL American Sign Language
Other
Chuukese
Nepali
Haitian-Creole
Somali
U.S. / Canadian Postal Code lookup
*
Country
--Select--
USA
Afghanistan
Aland
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
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Reunion
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Russia
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Saint Vincent and the Grenadines
Samoa
San Marino
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Senegal
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Sint Maarten
Slovakia
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Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
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Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
U.S. Minor Outlying Islands
U.S. Virgin Islands
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Vatican City
Venezuela
Vietnam
Wallis and Futuna
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Other
*
Address
City/Villa/Town
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State/Province
State/Province
--Select--
AK
AL
AR
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CO
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DE
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HI
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MA
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Please enter the name and phone number of someone who is NOT going to be staying at the Ronald McDonald House.
Emergency / Additional Contact name
Emergency / Additional Phone
Emergency Contact Relationship
*
Will the family be bringing a service dog? (companion and emotional support dogs do not qualify as service animals and are not allowed at our Houses)
No
  Yes
*
Does the family require an ADA Room?
We will do our best to accomodate, this is not guaranteed. Please reach out to the guest service team to check on availability after you submit your request. bend.house@ronaldmcdonaldhouseoregon.org
Please select a response
ADA Required
ADA Preferred but not required
No
Comments / Additional Needs