Go to the Ronald McDonald House Charities of Central Indiana website.
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)
*
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
*
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)
Pediatric Rehab
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)
Urology
Other
Guardian/Caregiver Information
*
Guardian/Caregiver Name (First and Last)
*
Relationship to patient
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
*
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
Second Guardian/Caregiver Name (First and Last)
Relationship to patient
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
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
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
Help Request Sent
Ok
Make sure the information below is complete and correct and click submit. Someone from the Ronald McDonald House will contact you.
Name of person completing this form
Patient Name ( First and Last )
Phone
Email
Submit
