Ronald McDonald House Charities Columbia, SC

 
Rooms cannot be reserved or held in advance.
 



*

*

*
Number in Guest Family Party:

Please fill out the following with the PATIENTS information:
*
*
*
*
*
Address:
U.S. / Canadian Postal Code lookup


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


*
*
*
*

Guest Family/Accompanying Guests
*
*
*
*
*
*
I agree to receive texts at this number.

*
*
*
*
I agree to receive texts at this number.

Additional Guests / Family Members

* * *

Add Another Guest
*
Do you or anyone in your guest party currently have an open case and/or are under investigation by law enforcement or any state child protection division for child abuse and/or neglect?
*
Have you or anyone in your guest party been convicted of a felony?
*
Does the PATIENT (or mother, if patient is a newborn) have Medicaid?
Medicaid Information
Medicaid Member Name:
Date of Birth:
Phone Number:
Physical Address:
City:
State:
Zip Code:
Date of Appointment:
Appointment time:
Facility Name:
Phone Number:
Fax Number:
Treating Physician:
Phyical Address:
City:
State:
Zip Code:
Treatment Type:
Please explain why the member needs to stay overnight:
If an escort is being requested to travel with the member, please complete the Medical Certification for Escort Form and attach. If the request is for a minor child, one adult escort (parent or guardian) will be automatically approved.