Online Registration

Online Registration

Welcome

Your Name

Phone

Have you stayed at Ronald McDonald House Charities of Greater Cincinnati in the past?

If yes, have you stayed in the past 2 years?

Patient Information
(To add additional patient(s), enter the information in the additional guest’s section below and select the ‘patient’ relationship.)

Check this box if you are a fetal care patient, if so, please input baby's information below and your information will go under "Guardian Contact Information."

* Patient Name ( First and Last )

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

* Patient Gender

* Patient Ethnicity

Diagnosis

Assigned Social Worker / Hospital Staff

Physician/Doctor

* Patient is being treated at:

* Department

Speciality

Will the patient be inpatient or outpatient?

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

* Date of first appointment at hospital

* Check In Date

* Check Out Date

Primary Language

PO boxes are not permitted

U.S. / Canadian Postal Code lookup

Country

Address

City/Villa/Town

County/District

State/Province

State/Province

Zip

Guardian Contact Information

Please enter information for the guardian(s) who will be staying at RMHC.

Please enter information for the guardian(s) who will be staying at RMHC.

* First Guardian Name

* Relationship to patient

First Guardian Gender

* Date of Birth (MM/DD/YYYY)

* Ethnicity

* Email

Primary Phone Number

I agree to receive texts at this number.

Please check this box if this number is able to receive text messages..You will receive a text from SlickText, please respond YES to opt in. Standard messages and data rates apply.

Alternate Phone

I agree to receive texts at this number.

Second Guardian Name

Relationship to patient

Second Guardian Gender

Date of Birth (MM/DD/YYYY)

Ethnicity

Primary Phone Number

I agree to receive texts at this number.

Please check this box if this number is able to receive text messages..You will receive a text from SlickText, please respond YES to opt in. Standard messages and data rates apply.

Additional Guest(s) Information

Will there be any additional guests at the House throughout your stay? Please enter their information below (siblings, aunts, uncles, cousins, etc).

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

Add Another Guest

Additional Information

* Emergency / Additional Contact name

* Emergency/Additional Phone Number

Family’s method of transportation to the hospital or our house?

Will you have a vehicle on premises?

Please enter car information below:

Please enter N/A below.

* Car Make/Model/Description

* Car License State

* License Plate#

Which of these describes your total household income? (Note: This information is only used in securing funding for the House.)

*

Does the patient have Medicaid?

Does the patient have Private Insurance?

* What is your Medicaid Id / Private Insurance Policy Number? (Type N/A if you do not have Medicaid or Private Health Insurance.)

* If Medicaid, which state? (Choose N/A if you do not have Medicaid.)

If Private Insurance, who is your insurance provider? (type N/A if you do not have private insurance)

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Help Request Sent

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