Texas Children's Hospital North Austin Day Pass Guest Request

1. Request:
Referrals only accepted from Hospital and Medical Staff Members or Victim Services personnel.

* Arrival Date

* Estimated Departure Date

2. Patient Information

* Patient Name ( First and Last )

* Patient Gender

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

* Patient Ethnicity

* Diagnosis

* Facility Treated At

* Will the patient be inpatient or outpatient?

Inpatient - Hospitalized Outpatient - Non-Hospitalized Both, during this stay.

* Patient Care Unit

* Does the Patient Have Medicaid?

3. Guest Information:
Day Pass access is subject to daily capacity limits to protect overnight guest availability and safety.

* Guardian/Caregiver Name (First and Last)

* Guardian/Caregiver Gender

* Date of Birth (MM/DD/YYYY)

* Relationship to patient

* Email

Home Phone

I agree to receive texts at this number.

* Mobile Phone

I agree to receive texts at this number.

Is this family currently experiencing homelessness?

Are any guests of the patient considered to have active duty military or veteran status?

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

State/Province

Zip

Second Guardian/Caregiver Name (First and Last)

* Guardian/Caregiver Gender

* Relationship to patient

* Date of Birth (MM/DD/YYYY)

* Email

* Primary Phone Number

I agree to receive texts at this number.

Additional Guests/Family Members/Patients: * * * I agree to receive texts at this number.

Add Another Guest

4. Additional Information:

Family agrees to allow hospital to share info with Ronald McDonald House Central Texas.

* Primary Language

* Referral Contact Name

* Referral Contact Phone and Extention

* Referral Contact Email

Have guardians been convicted of violence crimes, domestic violence, child abuse, and/or sex offenses or the subject of a pending violence case?

Is there an open or pending CPS case regarding this family or guardians?

Notes regarding this request: