East House Social Worker Return

Ronald McDonald House Charities of Oregon & Southwest Washington

Hospital Staff Information

* Your Name

* Phone

* Email

Reservation Information

You may request to check-in the day before the patient's appointment. You must check out by 12 pm the day after a patient's appointment.

If you are discharged early, you have until the next day by 12 pm to check out. (If you want to request an exception to stay longer after being discharged, please call Family Placement at 971-230-6702.)

* Date of first appointment at hospital

* Check In Date

* Check Out Date

Patient Information
To add additional patients, enter the information in the Additional Guests / Family Members section below and select the ‘patient’ relationship.

* Patient Name ( First and Last )

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

* Patient Gender

* Diagnosis (If unknown, enter in reason for visit: testing, trauma etc)

* Reason For Stay

* Department

* Patient is being treated at:

Assigned Social Worker/Hospital Staff

Primary Language

Will the patient be inpatient or outpatient?

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

* Medicaid ID (If patient does not have medicaid, type N/A)

* Medicaid Branch (If patient does not have Medicaid, choose "No Medicaid")

Family Information

If your address has not changed since your last stay, you do not need to fill out this information again.

U.S. / Canadian Postal Code lookup

Country

Address

City/Villa/Town

County/District

State/Province

Zip

Guardian Information

For return families, please ensure you are adding ALL Guardian names on the request (i.e both parents). If this is a family that has not stayed in the past year, their referral status will not update if you do not add all names and we will need them to do another refferal prior to check in.

* Guardian/Caregiver Name (First and Last)

* Date of Birth (MM/DD/YYYY)

Relationship to patient

Guardian/Caregiver Gender

* Primary Phone Number

I agree to receive texts at this number.

Second Guardian Information

Second Guardian/Caregiver Name (First and Last)

Date of Birth (MM/DD/YYYY)

Guardian/Caregiver Gender

Relationship to patient

Primary Phone Number

I agree to receive texts at this number.

Additional Guests / Family Members: I agree to receive texts at this number.

Add Another Guest

Additional Information

Is the patient still in utero?

No Yes

Expectant patients are allowed to stay up to two weeks before the scheduled delivery date. A referral from a social worker and a letter are required before the check-in date. Once you complete your registration request, please send a letter from the patient's provider to family@rmhcoregon.org that states the following.

Patient Name
Diagnosis of fetus
A statement that NICU admission is required at birth or fetal monitoring is required up to the due date.
Include the scheduled delivery date and the date the provider would like the patient to arrive

Does the family require an ADA Room?
We will do our best to accommodate, but this is not guaranteed. Please reach out to family placement to check on availability after you submit your request. Family@rmhcoregon.org.

Comments / Additional Needs

Will you be bringing a pet with you to the hotel? The DoubleTree Hilton has limited pet-friendly rooms. Family Placement will need to verify if there is one available if you intend to bring a pet with you.