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Day Use Pre-Registration
We are so glad you're here! Please complete the following questions as accurately as possible.
Patient Information
*
Patient Name ( First and Last )
*
Patient Date of Birth (MM/DD/YYYY)
Medicaid Id (if no medicaid, type N/A)
*
Patient Gender
Male
Female
Nonconforming
*
Patient Ethnicity
Please select a response
Aboriginal
Arab/Middle Eastern
Asian
Black/African Descent
East Indian
First Nation
Hispanic
Latino
Maori
Multi-Racial
Native American or Alaskan native
Pacific Islander
White/Caucasian
Other
Declined
Treatment Diagnosis
Allergy and Immunology
Behavioral and Developmental
Burn
Cardiology/Cardiac Surgery
Critical Care
Dermatology
Eating Disorders
Emergency Department
Emergency Medicine (Injury/Trauma/Accident)
Endocrinology and Diabetes
Gastroenterology and Hepatology
General Pediatrics and Adolescent Medicine
General/Day Surgery
Hematology/Oncology
High Risk Pregnancy
Infectious Disease
Mental Health
Metabolic Disease
Neonatal and Perinatal Medicine
Nephrology and Hypertension
Neurology/NeuroSurgery
Oncology
Ophthalmology
Orthopedics
other /none given on request
Otolaryngology (ENT)
Outpatient Appointment
Pain Rehabilitation
Pulmonology
Rheumatology
Stem Cell
Transplant
Department
Behavioral Health
Bone Marrow Transplant
Burn Unit
Cardiology | Diseases of the heart, blood vessels, and circulatory system
Endocrinology | Diseases related to problems with hormones such as diabetes
Gastroenterology | Diseases and disorders impacting the digestive system
Hematology/Oncology | Blood Disorders and/or Cancer
High Risk Pregnancy
Infectious Disease
Maternity Tower
Metabolic Medicine
Nephrology | Kidneys
Neurology | Brain, Spinal Cord, and Peripheral Nerves
Newborn Pediatrics
NICU | Neonatal Intensive Care Unit
Ophthalmology | Eyes
Organ Transplant
Orthopedics
Other/None given on request
Otolaryngology | Head and Neck | (ENT)
PICU | Pediatric Intensive Care Unit
Plastic Surgery
Psychiatry | Mental Disorders
Pulmonology | Respiratory Tract
Respiratory | Group of organs and tissues that work together to help you breathe
Rheumatology | inflammation in the bones, muscles, joints, and internal organs
Stem Cell Transplant
Surgery (General)
Other
Date of first appointment at hospital
Guardian/Caregiver Information
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Guardian/Caregiver Name (First and Last)
*
Relationship to patient
Mother
Father
Sibling
Grandparent
Step-Parent
Foster Parent
Legal Guardian
Aunt
Uncle
Cousin
Godparent
Significant Other/spouse of Patient
Niece
Nephew
Daughter
Son
Wife
Great Uncle
Great Aunt
Great Grandparent
Significant Other of Mother
Significant Other of Father
Husband
Friend of Patient/Friend of Family
Brother-In-Law of Patient
Sister-In-Law of Patient
Brother-in-Law
Sister-in-Law
Case Management/CPS/DCS
Caregiver - Staff of Treatment/Care Medical F
*
Guardian/Caregiver Gender
Male
Female
Nonconforming
*
Date of Birth (MM/DD/YYYY)
*
Ethnicity
Please select a response
Aboriginal
Arab/Middle Eastern
Asian
Black/African Descent
East Indian
First Nation
Hispanic
Latino
Maori
Multi-Racial
Native American or Alaskan native
Pacific Islander
White/Caucasian
Other
Declined
*
Primary Phone Number
*
Email
U.S. / Canadian Postal Code lookup
*
Country
--Select--
USA
Afghanistan
Aland
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos [Keeling] Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Curacao
Cyprus
Czechia
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar [Burma]
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
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
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
U.S. Minor Outlying Islands
U.S. Virgin Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
*
Address
City/Villa/Town
County/District
State/Province
State/Province
--Select--
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
PR
Zip
Second Guardian/Caregiver Name (First and Last)
Relationship to patient
Mother
Father
Sibling
Grandparent
Step-Parent
Foster Parent
Legal Guardian
Aunt
Uncle
Cousin
Godparent
Significant Other/spouse of Patient
Niece
Nephew
Daughter
Son
Wife
Great Uncle
Great Aunt
Great Grandparent
Significant Other of Mother
Significant Other of Father
Husband
Friend of Patient/Friend of Family
Brother-In-Law of Patient
Sister-In-Law of Patient
Brother-in-Law
Sister-in-Law
Case Management/CPS/DCS
Caregiver - Staff of Treatment/Care Medical F
Guardian/Caregiver Gender
Male
Female
Nonconforming
Date of Birth (MM/DD/YYYY)
Ethnicity
Please select a response
Aboriginal
Arab/Middle Eastern
Asian
Black/African Descent
East Indian
First Nation
Hispanic
Latino
Maori
Multi-Racial
Native American or Alaskan native
Pacific Islander
White/Caucasian
Other
Declined
Primary Phone Number
Email
Additional Guests
Will there be any additional guests visiting the family room with you? Please enter their information below (siblings, grandparents, aunts, uncles, cousins etc.)
Additional Guests / Family Members
Add Another Guest
Additional Information
Emergency Contact Name (for guardian/caregiver)
Emergency Contact Phone (for guardian/caregiver)
*
Photo Release I hereby grant to Ronald McDonald House Charities and all affiliates the irrevocable unrestricted worldwide right to use, publish, display, broadcast, edit, modify, and distribute materials bearing my name, voice, and image or any other identifiable representation of myself. RMHC use will be limited to use involving raising awareness of or for support of RMHC.
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How did you hear about us?
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Hospital Programs
Another Family
Medical Staff
Previous Guest
Social Work
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Name of person completing this form
Patient Name ( First and Last )
Phone
Email
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