Online Registration

* Have you stayed with us before?

Yes No

Patient Information

* Patient Name ( First and Last )

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

For Fetal Care patients please put your child’s expected date of delivery.

Patient Gender

* Patient Ethnicity

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

State/Province

Zip

* Patient is being treated at:

Department

* Diagnosis

* Will the patient be inpatient or outpatient?

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

* Assigned Social Worker / Hospital Staff

Physician/Doctor

* Date of first appointment at hospital

* Check In Date

* Check Out Date

Does the patient or family have health insurance? (CCS, CCAH, HSMA, Medi-Cal, private, etc.)

Provider name, Medical ID N., Phone No.

Contact Information

Guardian/Caregiver Name (First and Last)

* Relationship to patient

* Date of Birth (MM/DD/YYYY)

Guardian/Caregiver Gender

Guardian 1 Vaccination Status

* Primary Language

* Primary Phone Number

I agree to receive texts at this number.

* Second Guardian/Caregiver Name (First and Last)

* Relationship to patient

* Date of Birth (MM/DD/YYYY)

Guardian/Caregiver Gender

Ethnicity

* Primary Phone Number

I agree to receive texts at this number.

Emergency Contact First and Last Name

Alternate Phone

Guardian/Caregiver Name (First and Last)

Emergency Phone

Guests

Number of adults staying at our House including Guardians/Caregivers

Number of Children staying at our House including patient if staying at our House

Additional Guests / Family Members: Add Another Guest

Additional Information

Please write in your total monthly income for your household. (Do not include decimals.)

Is the family able to do stairs?

Are there any special needs for your family? (wheelchair, etc.)

Can we contact you via text/email?

Does the family have a credit/debit card?

Are there any contact isolation precautions for the patient or anyone in your family that will be staying at the house? If yes, please explain.

If preferred language is something other than English, please specify.

Is there anything else you would like us to know about the familiy?