Online Registration

* The patient receiving evaluation and/or treatment is 21 years of age or younger?

* Do any members of the guest party have symptoms related to contagious illnesses?

* 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?

* Are you or anyone in your guest party listed on the National Sex Offender Registry? (Note all guests ID's will be scanned upon arrival)

* Have you or anyone in your guest party been convicted of or are currently facing charges for a felony or violent criminal offense?

Patient Information

* Name (First & Last)

Patient Middle Name

* Patient Date of Birth

* Patient Vaccination Status

* Patient Gender

Family's Primary Language

* Patient Ethnicity

* Does the patient have Mediciad?

Medicaid Branch

Medicaid Id (if no medicaid, type N/A)

Medicaid if yes, brief description of what patient is being seen for

* Date of first appointment at hospital

* Will the patient be inpatient or outpatient?

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

* If out-patient: Date of last appointment at hospital (MM/DD/YYYY)

* Department

Diagnosis

* Requested Check In

* Expected Check Out

* Patient is being treated at:

* Physician/Doctor

Patient's Primary Address

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

State/Province

Zip

Family Contact Information

* Guardian Name

Guardian Middle Name

* Guardian Relationship

* Guardian Date of Birth

* Guardian Gender

* Guardian Ethnicity

* Guardian Email

* Guardian Phone

Guardian 2 Name

Guardian 2 Relationship

Guardian 2 Date of Birth

Guardian 2 Gender

Guardian 2 Ethnicity

Guardian 2 Phone

Additional Guests

Additional Guests / Family Members: Add Another Guest

Please provide the name and phone number of a relative or friend of the patient's family in the event staff cannot get in touch with the patient’s family.

* Emergency / Additional Contact name

* Emergency / Additional Phone

Additional Information for your stay

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

* Will you have a vehicle on premises?

* Car Make/Model/Description

* Car License State

* License Plate#

Does anyone in the guest party need a wheelchair accessible room?

Any additional information you would like to add?

* I certify that the above information is true and correct.