* 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


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Patient Middle Name
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* Does the patient have Mediciad?
Medicaid if yes, brief description of what patient is being seen for
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Inpatient - Hospitalized   Outpatient - Non-Hospitalized   Both, during this stay.

* If out-patient: Date of last appointment at hospital (MM/DD/YYYY)
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Patient's Primary Address

U.S. / Canadian Postal Code lookup


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Family Contact Information


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Guardian Middle Name 
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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.
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Additional Information for your stay

Family’s method of transportation to the hospital or our house?
* Will you have a vehicle on premises?
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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.