Return Family Stay Request

This form is for families who have stayed at Ronald McDonald House South Florida within the past 30 days. This request must be completed by the family’s social worker. Please provide the information for the new stay and let us know if anything has changed since the family’s last visit.

All stay requests must be reviewed and confirmed by Ronald McDonald House staff before arrival.

Has the family stayed at Ronald McDonald House South Florida in the past 30 days?

* Assigned Social Worker / Hospital Staff

* Patient is being treated at:

* Patient Name ( First and Last )

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

* Department

* Diagnosis

* Check In Date

* Check Out Date

Will the patient be inpatient or outpatient?

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

Please provide any special needs or accommodations, such as wheelchair accessibility, a Pack ’n Play, an air mattress, or a private bathroom. If requesting a private bathroom, please explain why one is needed.

Has the patient's insurance changed since the last stay?

Yes

Patient is currently uninsured

List all guests who will be staying below:: Add Another Guest

* Guardian Email Address (Please provide an email address that the guardian checks regularly so we can share important updates and information.)

Primary Phone Number

I agree to receive texts at this number.