Patient Information:

*
*

*
Did you know about the Ronald McDonald House prior to your stay?
Yes No
*
In using our services would you be willing to support the Ronald McDonald House in the future?


Please rate the following areas on a scale of 1 to 5 (1 being the lowest & 5 being the highest)

*
1. Registration Process
1
2
3
4
5

*
2. Friendliness of Staff
1
2
3
4
5

*
3. House Cleanliness
1
2
3
4
5

*
4. Room Quality
1
2
3
4
5

*
5. Your Overall Stay
1
2
3
4
5



Did you have a comforting and relaxing experience?
 
Yes No
*
*
What is the distance from your home to the Ronald McDonald House?
 
Is your total household income below $25,000?
Yes No

Please share any comments, suggestions or concerns that can help us improve our services.