Go to the RMHC RRV website.
Ronald McDonald House Referral
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Date of first appointment at hospital
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Requested Check In Date: (Rooms can be requested up to 1 day prior to the appointment date).
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Child's Name
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Childs Date of Birth
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Location of Treatment
Essentia Health
Prairie St. Johns
Roger Maris Cancer Center
Sanford Eating Disorder Institute/Feeding Clinic
Sanford Health
Other
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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
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Parental/Guardian Name
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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
I agree to receive texts at this number.
Parental/Guardian Email
Comments
Please accept this submission as proof of admission/treatment.
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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
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