Return Family Registration

Ronald McDonald House Charities of Oregon & Southwest Washington

Pediatric Social Worker Return Guidelines
• Patients over 18 and caregiver(s) must pass regular screening criteria.
• Rooms can accommodate a maximum of 6 people.
• Every guest family member (including patient) must pass a health screening to ensure that they are symptom-free.
• Guests (if over 18) must sign "Stay Agreement" document at check-in.

Social Workers: Please remember to enter in Patient's Full name and Birthday correctly. Otherwise, it will not recognize the patient as a return and you will not be able to use this portal to submit a request.

Hospital Staff Information

* Your Name

* Phone

* Email

Reservation Information

* Date of first appointment at hospital

* Check In Date

* Check Out Date

House Location: East House for Randall Hospital or South Waterfront for Doernbecher Hospital

Patient Information

* 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

Physician/Doctor

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 Contact 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

Do you consent to Family Placement contacting you via text? (message and data rates may apply)

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

Do you consent to Family Placement contacting you via text? (message and data rates may apply)

Additional Guests / Family Members: Add Another Guest

Additional Information

Is the patient still in utero?

* Will your family be bringing a service dog? (companion and support dogs do not qualify as service animals and are not allowed at our Houses)

No Yes

Does the family require a room with a kitchen? (Only applies for East House Location)
We will do our best to accomodate, this is not guaranteed. Please reach out to family placement to check on availability after you submit your request. Family@rmhcoregon.org.

Does the family require an ADA Room?
We will do our best to accomodate, 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