Go to the RMHC RRV website.
Ronald McDonald House Referral
*
Date of first appointment at hospital
*
Requested Check In Date: (Rooms can be requested up to 1 day prior to the appointment date).
*
Child's Name
*
Childs Date of Birth
*
Location of Treatment
Essentia Health
Prairie St. Johns
Roger Maris Cancer Center
Sanford Eating Disorder Institute/Feeding Clinic
Sanford Health
Other
*
Diagnosis Category
Allergy and Immunology
Auto-Immune Disease
Behavioral and Developmental
Blood Disorder
Cardiology/Cardiac Surgery
Dermatology
Eating/Feeding Disorders
Emergency (Injury/Trauma/Accident)
Endocrinology and Diabetes
Gastroenterology and Hepatology
General Outpatient Appointment
General/Day Surgery
High Risk Pregnancy
Infectious Disease
Kidney Disease
Mental Health
Neurology/Neurosurgery
NICU (Neonatal ICU)
Oncology (Cancer)
Ophthalmology
Orthopedics
Otolaryngology (ENT)
Pain Rehabilitation
Pediatrics
PICU (Pediatric ICU)
Pulmonology
*
Parental/Guardian Name
*
Relationship to patient
Patient
Mother
Father
Sibling
Grandparent
Relative
Friend of Family
Step-Parent
Parent's S.O.
Patient's S.O.
Parental/Guardian Phone Number
Parental/Guardian Email
Comments
Please accept this submission as proof of admission/treatment.
*
Signed by Electronic Signature:
Please select a response
Other
Help Request Sent
Ok
Name of person completing this form
Patient Name ( First and Last )
Phone
Email
Submit
