Online Registration

* Staff/Social Work Name

* Phone

* Hospital

* Department

* Has family 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 Insurance

* Patient Gender

* Patient Ethnicity

Assigned Social Worker / Hospital Staff

* Reason For Stay

* Diagnosis

* Assigned Social Worker / Hospital Staff

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. Does caregiver/parent have a valid ID?

* 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

Is family eligible to stay at RMH or Family House?

Is there a history of substance/alcohol abuse?

Is there a history of suspected child/domestic abuse?

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

Does the patient have CCS? If so, which county?

Does this patient have an infectious disease or virus (RHINO, MRSA, CRONO, COVID, etc?

If yes, please explain.

Is the family able to do stairs?

Are there any special medical needs for this family? (Wheelchair, etc.)

* Can we contact you via text/email message?

What name should reservation of hotel be under?

Does family have a credit/debit card?

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

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