Online Registration

* Have you stayed at UCSF Benioff Children's Hospital - San Francisco Housing in the past?

Yes No

If yes, Have you stayed at Ronald McDonald House of San Francisco or Family House in the past 12 months?

* Patient Name ( First and Last )

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

Patient must be 18 years or younger. In the case of Fetal Care patients, the patient will be regarded as the unborn child. For Fetal Care patients please put your child’s expected date of delivery.

* Patient Insurance

* Patient Ethnicity

* Patient Gender

* Reason For Stay

* Diagnosis

* Assigned Social Worker / Hospital Staff

* Patient is being treated at:

Department

* Will the patient be inpatient or outpatient?

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

* Date of first appointment at hospital

* Lodging Check-In Date

* Lodging Check-Out Date

All caregivers visitors over 18 must have a valid ID. Please confirm you have a valid government issued ID by checking the box below.

* Guardian/Caregiver Name (First and Last)

* Relationship to patient

* Guardian/Caregiver Gender

* Date of Birth (MM/DD/YYYY)

* Ethnicity

* Primary Phone Number

Alternate Phone

Primary Language

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

Zip

Please provide the name and phone number of a relative or friend of the patient's family in the event staff cannot get in touch with the patient’s family.

Emergency / Additional Contact name

Emergency / Additional Phone

Additional Guests / Family Members: * * *

Add Another Guest

Can we contact you via text/email message?

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

* 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 yes, please explain.

How many people are you financially responsible for that live in your home, including yourself? For example: If you (+1) live at home with your spouse (+1), your two children (+2), and your adult brother, select only “4 people” from the list below.

* Does the patient have private insurance? If yes, please provide contact information/fax number for authorization.

* Does the patient have CCS? If yes, which county (California Children's Services) ?

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

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