Online Registration
Ronald McDonald House of South Louisiana
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Assigned Social Worker / Hospital Staff
Please select a response
Meron Azage
Mary Balik
kathleen Barre
Katie Barre
Miranda Bartholomew
Shanah Bartram
Ashley Belding
Laura Bullock
Crystal Burns
Dr. Paul Celeste
Kristen Charbonnet
B. Cheremie
Shirley Colvin
Brianna Duplessis-Gilbert
Dr. Beth Fancher
Sarah Fontana
Heidi Fox
Casey Franklin
Elizabeth Frein
Tanya Gilbert
Carolyn Gilcrease
Juliette Harch
Jamie Johnson
Mallory Lafargue
Courtney Lafont
Dwuan Magee, RN
Arian Manger
Summer McDaniel
Kristine Miller
Eva Morova
Jamie O'Berry
Alice O'keefe
Dr. Joseph Ortenberg
Joy Parker
Lisa Patrinino
Becky Peters
Jhane Philips
Dr. Jeffrey Poole
Deborah Puig
Alex Redfearn
Trey Roberts
Brianne Robinson
Amy Ronnenburg
Keri Rousse
Margarita Salmon
Alison Schreefel
Lois Simon
Lauren Sisk
Kayley Surrette
Annie Vaden
Lindsey Wiley
Gwen Yeager
Dr. Lolie Yu
Other
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Social Worker Email
Social Worker Phone:
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Patient is being treated at:
Children's Hospital
East Jefferson General Hospital
Family Physicians' Center (Harch HBOT)
North Oaks Medical Center
Ochsner - Kenner
Ochsner - Westbank
Ochsner Baptist
Ochsner Hospital for Children
Ochsner Main Campus
Poole Dermatology Clinic
River Oaks Hospital
Touro
Trinity Neurologic Rehab Center
Tulane Lakeside
Tulane Medical Center
University Medical Center (LSU)
Other
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Department
Bone Marrow Transplantation Immune Deficiency
Bronchology
Cardiology
Child and Adolescent Psychiatry
Colorectal
Coronary Care Unit
Craniofacial Center
Cystic Fibrosis
Dermatology
Developmental and Behavioral
Down Syndrome
Ear Nose and Throat
Emergency Department
Endocrinology
Eosinophilic Disorders
Fetal Care Center
Gastroenterology
Genetics
Gynecology
Heart Transplant
Hematology
ICU
Kidney Transplant
Liver Transplant
Liver Transplant
NBIC
Nephrology
Neurology
Neurosurgery
Newborn Intensive Care NICU
Occupational Therapy and Physical Therapy
Oncology
Orthopedic
Otolaryngology Head and Neck Surgery
Palliative Care
Pediatric Surgery
Physical Disabilities
PICU - Pediatric Intensive Care Unit
Plastic Surgery
Pulmonary
Radiology and Medical Imaging
Rehabilitation
Rheumatology
Sleep Disorder
Small Bowel Liver Pancreas Transplant
Speech Pathology
Surgical Weight Loss
Thoracic Surgery
Urology
Vascular
Other
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Patient Name ( First and Last )
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Patient Date of Birth (MM/DD/YYYY)
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Medicaid Id (if no medicaid, type N/A)
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Patient Gender
Male
Female
Nonconforming
Unborn
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Patient Ethnicity
Please select a response
Aboriginal
Arab/Middle Eastern
Asian
Black/African Descent
East Indian
First Nation
Hispanic
Latino
Maori
Multi-Racial
Native American or Alaskan native
Pacific Islander
White/Caucasian
Other
Declined
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Reason For Stay
Cancer
Eye
Heart
Kidney
Neurology
Other (non-surgical)
Other (surgical)
Pediatric Cancer
Pediatric Cardiology
Pending - Children's Patient
Premature
Unknown - exploratory
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Will the patient be inpatient or outpatient?
Inpatient - Hospitalized  
Outpatient - Non-Hospitalized  
Both, during this stay.
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Anticipated Check in Date
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Anticipated Check out Date
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Primary Guardian Name
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Relationship to patient
Patient
Mother
Father
Sibling
Grandparent
Relative
Friend of Family
Step-Parent
Parent's S.O.
Patient's S.O.
Unknown
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Primary Phone Number
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Email
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Second Guardian/Caregiver Name (First and Last)
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Relationship to patient
Patient
Mother
Father
Sibling
Grandparent
Relative
Friend of Family
Step-Parent
Parent's S.O.
Patient's S.O.
Unknown
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Primary Phone Number
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Email
Additional information about this family:
Help Request Sent
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Name of person completing this form
Patient Name ( First and Last )
Phone
Email
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