Spokane

Who is completing this registration:

Have you stayed with us before?

Preferred language if not English?

Who are you caring for?

Patient Information:

* Patient Name ( First and Last )

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

* Patient Gender

Patient Ethnicity

Does the patient or guardian have state insurance?

Medicaid ID (If applicable)

Medicaid Branch

If the family has private insurance, please add the provider and # if possible.

Reason For Stay

Additional diagnosis information (i.e.: number of weeks premature, type of cancer, etc.)

* Will the patient be inpatient or outpatient?

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

* Department

* Patient is being treated at:

* Assigned Social Worker / Hospital Staff

Who will be staying at RMHC INW?

Parent/Guardian Information:

* Guardian/Caregiver Name (First and Last)

* Relationship to patient

Primary Phone Number

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

Zip

Date of Birth (MM/DD/YYYY)

* Guardian/Caregiver Gender

Ethnicity

2nd Parent/Guardian Information:

* Relationship to patient

Second Guardian/Caregiver Name (First and Last)

Primary Phone Number

Date of Birth (MM/DD/YYYY)

* Guardian/Caregiver Gender

Ethnicity

Additional Guests / Family Members: * * * *

Add Another Guest

When can we expect you?

* Check In Date

* Anticipated Check Out Date

Special accommodations or other information we should know? (ex: hearing impaired, ADA accessibility required, etc.)

Online Registration

Spokane

Who are you caring for?

Who will be staying at RMHC INW?