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
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 (If unknown or you do not see your social worker's name, choose "Other" at the very bottom of the dropdown menuand enter in "Unknown" or your social worker's name.)

Primary Language

Will the patient be inpatient or outpatient?

* 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

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)

Email

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 Information 

Is the patient still in utero?

Expectant mothers are allowed to stay up to two weeks prior to scheduled delivery date. A referral from a social worker and a letter is required in order to be considered to stay. Once you complete your registration request, please send a letter from the patients provider to family@rmhcoregon.org that states the following. 

• Mothers Name
• Diagnosis of fetus
• Statement that the baby will require medical intervention prior to delivery date
• Include the scheduled delivery date and the date the priovider would like the patient to arrive

* 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)

Does the family require a room with a kitchen? (Only applies for East House Location and is prioritized for patients who are immunocompromised)
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