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

* Patient Ethnicity

Treatment Diagnosis

Department

Date of first appointment at hospital

Guardian/Caregiver Information

* Guardian/Caregiver Name (First and Last)

* Relationship to patient

* Guardian/Caregiver Gender

* Date of Birth (MM/DD/YYYY)

* Ethnicity

* Primary Phone Number

* Email

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

Zip

Second Guardian/Caregiver Name (First and Last)

Relationship to patient

Guardian/Caregiver Gender

Date of Birth (MM/DD/YYYY)

Ethnicity

Primary Phone Number

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.

How did you hear about us?

If 'other' who told you about us?