Online Registration

* Have you stayed with us before?

Yes No

Have you stayed at another RMHC location? Where?

Patient Information

* Patient Name

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

Patient Demographics

Patient Gender

How would you describe your patient's race?

Is the patient Hispanic, Latino/a, or Latinx?

Yes

Prefer not to answer

If you selected 'Other', please describe:

Patient Address

Begin by entering your zip code in the first field. This will automatically populate your city, county, and state.

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

State/Province

Zip

Hospital Stay Information

* Patient is being treated at:

Department

* Diagnosis

* Will the patient be inpatient or outpatient?

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

* Assigned Social Worker / Hospital Staff

Physician/Doctor

* Date of First Appointment at the Hospital

Housing Request Details

* Requested RMH Check In Date

* Estimated RMH Check Out Date

Insurance Details

Does the patient or family have health insurance?

If you have insurance, please provide the following information in the box below and contact your provider to request a lodging pre-authorization.

Insurance Provider Name
Medical ID Number
Phone Number On Your Insurance Card

Does family have a credit/debit card?

Yes No

Caregiver Information

* Guardian Name

* Relationship to patient

* Date of Birth (MM/DD/YYYY)

* Primary Language

If preferred language is not listed, please list here:

* Primary Phone Number

I agree to receive texts at this number.

Can we contact you via text/email message?

Yes No

Second Guardian Name

Relationship to patient

Date of Birth (MM/DD/YYYY)

Primary Phone Number

I agree to receive texts at this number.

Additional Guests / Family Members: Add Another Guest

Additional Family Information

How many people usually live in your home, including yourself?

Annual Household Income (Before Taxes)

What was the total combined gross income last year for you and the family members you live with?

In the last 12 months, did you ever worry that your food would run out before you got money to buy more?

Special Accommodations Needed?

Is everyone able to do stairs?

Are there any special needs for your family? (wheelchair, breast pump, fridge, freezer, pack n play, etc.). If yes, please describe below.

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.

Anything else?

Please share additional details that you'd like our Ronald McDonald House team to know about your family or this housing request below: