Hospital Referral Room Request

Thank you for your interest in referring a family to the Philadelphia Ronald McDonald House.
This form is for hospital staff members to complete on behalf of a family. Please note that a hospital referral is required for new families, international families, or families that haven't stayed with us within the past two years.

By submitting a room request, you acknowledge that you have reviewed and understand the
policies and procedures listed on our website under the Staying With Us tab.

For questions or updates about this request, please contact Family Services at
RoomRequests@rmhcphilly.org or 267-969-6220. Our team is available seven days a week from 9:00 AM to 5:00 PM.

A red asterisk * indicates a required field.

RMHC Philadelphia and RMH of Southern New Jersey work together to serve the Philadelphia region and utilize a shared database system to ensure that families are served efficiently. Please acknowledge that you have confirmed the family’s understanding and consent that all information entered into the room request form below will be available to both organizations. If you have questions before proceeding, please do not hesitate to call us at (267) 969-6220.

* Your Name

* Phone

* Email

PATIENT INFORMATION
To add an additional patient, use the additional guest block below and select "patient" under the relationship field.

* Patient Name ( First and Last )

* Patient Gender

* Patient Date of Birth or Estimated D.O.B. if Unborn

* Primary Language

TREATMENT INFORMATION

* Date of first appointment at hospital

* Check In Date

* Check Out Date

* Patient is being treated at:

* Will the patient be inpatient or outpatient?

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

* Diagnosis (If unlisted, specify if the notes section)

* Reason for Visit (Follow-up appointment, surgery, testing, etc.)

* Primary Hospital Department

Physician

* Hospital Social Worker

Hospital Social Workers Phone Number

PATIENT/GUARDIAN ADDRESS
Families are qualified to stay if they live 25 miles or more from the House

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

State/Province

Zip

GUARDIAN INFORMATION

* Guardian/Caregiver Name (First and Last)

* Guardian/Caregiver Gender

* Date of Birth (MM/DD/YYYY)

* Relationship to patient

* Primary Phone Number

I agree to receive texts at this number.

* Email

Second Guardian/Caregiver Name (First and Last)

Guardian/Caregiver Gender

Date of Birth (MM/DD/YYYY)

Relationship to patient

Primary Phone Number

I agree to receive texts at this number.

ADDITIONAL ROOM OCCUPANTS
Please note that each room can only accommodate up to 4 individuals.

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

Add Another Guest

ACCOMMODATION REQUESTS

Do any guests use a service animal?

If yes, please provide the name of the service dog and the type of service it provides. Proof of rabies vaccination is required prior to arrival.

Do any guests use a wheelchair or medical equipment?

If yes, please list the name(s) and the pertinent information:

GENERAL REQUEST NOTES:

Enter email for receipt of submission