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bienvenido
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En caso afirmativo, ¿te has quedado en los últimos 2 años?
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Información para el paciente
Check this box if you are a fetal care patient, if so, please input baby's information below and your information will go under "Guardian Contact Information."
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Nombre del paciente (Nombre y apellido)
*
Fecha de nacimiento del paciente (MM/DD/AAAA)
*
Sexo del paciente
Varón
Hembra
Género no conforme
No binario
No nacido
Declinado
*
Origen étnico del paciente
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Aboriginal
Arab/Middle Eastern
Asian
Black/African Descent
East Indian
First Nation
Hispanic
Latino
Maori
Multi-Racial
Native American or Alaskan native
Pacific Islander
White/Caucasian
Other
Declined
*
Diagnóstico
*
Trabajador social
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Meghan (Nutter) Herrick
Jennifer Adams
Kayla Akers
Liz Alfano
Carla Allen
Meg Angstadt
Julie Arnold
Amy Auberger
Kelly Baker
Jozie Banas
Carly Barnett
David Belle
Anwyn Bishop
Jen Blomer
Meredith Bohache
Jamie Brauley
Hannah Briner
Katie Brinker
Elizabeth Bross
Brianna Bruan
Beth Buelterman
Sarah Buzek
Kris Cagle
Allie Calhoun
Abigail Campbell
Esther Cash-Mills
Shelby Christen Oliphant
Danielle Christopher
Stephanie Coffey
Tracy Colliers
Samantha Conley
Samantha Connellan
Rowan Connors
Taylor Courtright
Carly Coz
Jen Crail
Emily Crowder
Jocelyn Culbreath
Kathy Daley
Beth DeGroft
Nancy Delaney
Brittany Dreier
Laura Edelberger
Jamaira Ellis
Stephanie Ellis
Dorothy Evans
Carrie Fiasco
Megan Florek
Ivy Flynn
April Fong
Brandi Forbes
Ericka Fortson
Hannah Frey
Ashton Fullenkamp
Erin Gluff
Lonnie Gow
Marlesha Grant
Muzna Gulamali
Katelyn Haager
Jennifer Haas
Jordee Harper
Molly Haskell
Kelly Hedges-Pelle
Evelyn Heflin
Sam Heister
Leah Hinson
Lydia Hinton
Margaret (Maggie) Hoffman
Amy Holden
Jackie Holford
Jessica Holliday
Drea Houchen
Robin Hurdle
Beth Hutson
Samantha Ingham
Felisha Jackson-Ilyas
Kevin Jacobson
Zee Johnson
Olivia Johnston
Jillisa "Jill" Jones
Joelene Kammer
Astrid Karn
Yisroel Kaufman
Noelle Keller
Megan Kelly
Michael Kelsch
Megan Kendall
Bridget Kikta
Stephanie Kisling
Erica Krompecher
Halsey Krupp
Lora Kurtz
Erin Laffrey
Jenna Leisure
Corinne Lewis
Taylor Limbach
Debbie Litteral
Kate Lowes
Megan Luneke
Amy Mahan
Krista Mann
Emilee Marsh
Gail McCullom
Tyler McCullough
Tiffany McDonald
Connor McGlinchey
Lauren McKelvey
Raquel McKinney
Margaret Melton
Wanda Meriwether
Anna Metz
Jamie Miller
Libby Miller
Nicole Mollica
Laura Monhollen
Molli Monk
Sue Moore
LaDonna Morales
Grace Moriarty-Evans
Rachel Mousie
Maureen Mulligan
Karen Murphy
Alisa Nelson
Christina Norris
Andrea O'Brien
Colleen Onders
Celia Paige
Katarina (Kat) Palmer
Abbey Pfefferman
Samantha Pierson
Theresa Popelar
Stephanie Powers
Jacqueline Rapose
Marlee Recker
Stephanie Rice
Liz Robinson
Jamie Rose
Abbey Rubenecker
Whitney Ruble
Kami Runzo
Lauren Samuel
Bobbie Sanderson
Ashley Santana
Stefanie Schaffer
Kaitlyn Schenkel
Claire Scott
Jessica Seal
Katelyn Seals
Leanna Shaw
Katie Shea
Linda Smets-Ullrich
Addie Smith
Elizabeth Smith
Laura Smith
Stacy Smith
Julie Smith-Swejkar
Michelle Spaulding
Elyse Stephenson
Maggie Stets
Christie Stewart
Shyan Stivers
Heather Strief
Sarah Sweeney
Callie Talbot
Denise Taylor
Kathryn Tell
Alyssa Theuerling
Emily Thiem
Amy Thomas
Kristin Todd
Emily Tumblison
Kristin Vargo
Alyssa Vollman
Maggie Waddell
Lindy Walker
Melinda Webster
Sondra Weingartner
Amie Wheeler
Morgan Whitlow
Molly Williams
Lindsay Wilson
Monica Wolking
Regina Woods
Ashley Wright
Courtni Wright
Lynn Young
Other
Médico/Doctor
*
Paciente está siendo tratado en:
Burnet Campus: Cincinnati Children's Hospital (Main Campus)
College Hill: Cincinnati Children's Hospital
Good Samaritan
Liberty Campus: Cincinnati Children's Hospital
Linder Center of Hope
University of Cincinnati Medical Center
Other
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Departamento
Adolescent and Transition Medicine
Allergy, Asthma and Immunology
Anesthesiology and Pain Management
Behavioral and Mental Health
Blood Diseases (Hematology)
Cancer (Oncology)
Critical Care
Developmental Disorders
Ear, Nose and Throat (ENT)
Emergency
Endocrinology and Diabetes
Everyday Health
Eyes (Ophthalmology)
Fetal Care
Gastroenterology
Genetics
Heart (Cardiology)
Immunodeficiency and Histiocytosis
Infectious Diseases
Kidney (Nephrology)
Liver (Hepatology)
Lungs (Pulmonology)
Neonatology
Neurology and Neurosurgery
NICU
Orthopaedics
PICU
Radiology and Imaging
Rehabilitation Medicine
Rheumatology
Skin Conditions (Dermatology)
Speech-Language Pathology
Sports Medicine
Surgery
Transplants
Urology
Other
Especialidad
Adolescent and Transition Medicine
Differences of Sex Development (DSD) Center
Eating Disorders
Gynecology
MRKH Care Center
Primary Ovarian Insufficiency Center
Teen Health Center
Transgender Health Center
Allergy and Immunology
Cincinnati Center for Eosinophilic Disorders
Anesthesia
Functional Independence Restoration Program
Pain Management Center
Perioperative Pain Management
Behavioral Medicine and Clinical Psychology
Brain Health and Wellness Center
Center for ADHD
Eating Disorders
Mental and Behavioral Health Institute
Neurodevelopmental and Educational Clinic
Neuropsychology
Psychiatry
Bone Marrow Transplantation Program
Cancer and Blood Diseases Institute
Comprehensive Fertility Care and Preservation Program
Fanconi Anemia Comprehensive Care Center
Hemangioma and Vascular Malformation Center
Hemophilia and Bleeding Disorders Program
Hemostasis and Thrombosis Center
HHT (Hereditary Hemorrhagic Telangiectasia) Center of Excellence
Sickle Cell Center
Thrombosis Program
Bone Marrow Transplantation Program
Brain Tumor Center
Cancer
Cancer and Blood Diseases Institute
Cardio-Oncology Program
Comprehensive Fertility Care and Preservation Program
Hereditary Cancer Program
Kidney Tumor Program
Leukemia and Lymphoma Program
Live Tumor Program
Neuroblastoma Advanced Therapies Center
Neurofibromatosis Program
Proton Therapy
Retinoblastoma Program
Sarcoma Program
Young Adult Cancer Center
Cardiac Intensive Care
Comprehensive Children's Injury Center
Pediatric Intensive Care Unit (PICU)
Trauma Services
Developmental and Behavioral Pediatrics
Kelly O'Leary Center for Autism Spectrum Disorders
Perlman Center
Rubinstein-Taybi Syndrome
Spina Bifida Center
Thomas Center for Down Syndrome
TrYAD Transition Clinic
Aerodigestive and Esophageal Center
Airway Reconstruction
Audiology
CHARGE Syndrome
Cleft and Craniofacial Center
Cochlear Implant Program
Ear and Hearing Center
Otolaryngology
Voice Disorders
Diabetes Center
Differences of Sex Development (DSD) Center
Endocrinology
Pancreas Care
Primary Ovarian Insufficiency Center
Center for Better Health and Nutrition
General and Community Pediatrics
International Adoption Center
International Travel Clinic
Primary Care Offices
Reading and Literacy Discovery Center
Teen Health Center
CHARGE Syndrome
Ophthalmology
Cincinnati Children's Fetal Care Center
Congenital Diaphragmatic Hernia Program
Fetal Heart Program
Celiac Disease Center
Center for Autoimmune Liver Disease
Colorectal
Gastroenterology, Hepatology, and Nutrition
Inflammatory Bowel Disease Center
Interventional Endoscopy
Intestinal Rehabilitation
Liver Care Center
Liver Transplant
Neurogastroenterology and Motility Disorders
Pancreas Care
Steatohepatitis Center
Cardiovascular Genetics
Cleft and Craniofacial Center
Epigenetic Syndromes Clinic
Hereditary Cancer Program
Human Genetics
Hypermobility Clinic
Lysosomal Storage Disorder Clinic
Rare Genetic Disease Program
Rasopathy Clinic
Skeletal Clinic
The 22Q-Velocardiofacial Syndrome Center
Thrombotic Microangiopathy
Adult Congenital Heart Disease Program
Arrhythmia and Electrophysiology
Cardiac Catheterization and Intervention
Cardiac Intensive Care
Cardiac MRI Program
Cardiac Rehabilitation
Cardio-Oncology Program
Cardiology
Cardiomyopathy Center
Cardiorespiratory Sports Clinic
Cardiovascular Genetics
Center for Better Health and Nutrition
CHARGE Syndrome
Coronary Artery Clinic
Fetal Heart Program
Fontan Management Clinic
Heart and Mind Wellbeing Clinic
Heart Institute
Heart Surgery
Heart Transplant
Hypertension (Cardiology)
Lipid Clinic
Neurodevelopmental and Educational Clinic
Neuromuscular Cardiology
Preventive Cardiology
Pulmonary Hypertension
Single Ventricle Interstage Clinic
Vascular Ring and Aortic Uncrossing Program
Ventricular Assist Device
Bone Marrow Transplantation Program
Cancer and Blood Diseases Institute
Comprehensive Fertility Care and Preservation Program
Histiocytosis Center
HLH Center of Excellence
Immune Deficiencies and Dysregulation Program
Infection Prevention and Control Program
Infectious Diseases
Acute Care Nephrology
Dialysis
End-Stage Renal Disease
Kidney Clinic
Kidney Transplant
Nephrology and Hypertension
Stone Center
Center for Autoimmune Liver Disease
Liver Care Center
Liver Transplant
Steatohepatitis Center
Aerodigestive and Esophageal Center
Asthma Center
Bronchopulmonary Dysplasia (BPD) Center
Bronchoscopy
Cardiorespiratory Sports Clinic
Cystic Fibrosis Center
End-stage Lung Failure Program
Home Ventilator
Lung Transplant Program
Pulmonary Hypertension
Pulmonary Medicine
Rare Lung Diseases
Respiratory Crea
Bronchopulmonary Dysplasia (BPD) Center
Center for Breastfeeding Medicine
Congenital Diaphragmatic Hernia Program
Differences of Sex Development (DSD) Center
Neonatology
Neuro NICU
Newborn Intensive Care Unit
NICU Follow-Up Clinic
Perinatal Institute
Brain Health and Wellness Center
Brain Tumor Center
Cerebral Palsy Program
Cerebrovascular Disease and Stroke Center
Comprehensive Epilepsy Center
Comprehensive Neuromuscular Center
Craniosynostosis and Cranial Reconstruction Center
Headache Center
Movement Disorders Clinic
Multiple Sclerosis and Neuroimmunology Center
Neurofibromatosis Program
Neurology
Neuropsychology
Neurosurgery
Retinoblastoma Program
Rett Syndrome
Sleep Center
Tuberous Sclerosis Clinic
Brachial Plexus Center
Crawford Spine Center
Hand and Upper Extremity Center
Hip Preservation Program
Limb Lengthening and Reconstruction Center
Orthopaedics
Cardiac MRI Program
Interventional Radiology
Radiology and Medical Imaging
Vascular Access
Cardiac Rehabilitation
Cerebral Palsy Program
Functional Independence Restoration Program
Occupational Therapy and Physical Therapy
Perlman Center
Rehabilitation Medicine
Autoinflammatory Disease
Lupus Center
Multiple Sclerosis and Neuroimmunology Center
Rheumatology
Dermatology
Epidermolysis Bullosa Center
Audiology
Cochlear Implant Program
Speech-Language Pathology
Voice Disorders
Brain Health and Wellness Center
Cardiorespiratory Sports Clinic
Occupational Therapy and Physical Therapy
Sports Medicine
Chest Wall Center
Cleft and Craniofacial Center
Colorectal
Craniosynostosis and Cranial Reconstruction Center
General Thoracic Surgery
Heart Surgery
Heart Transplant
Neurosurgery
Pituitary and Skull Base Surgery Center
Plastic Surgery
Surgical Weight Loss for Teens
Ventricular Assist Device
Bone Marrow Transplantation Program
Heart Transplant
Kidney Transplant
Liver Transplant
Lung Transplant Program
Posterior Urethral Valves
Stone Center
Urology
*
¿El paciente será será un paciente internado o ambulatorio?
Paciente Interno- Hospitalizado
Paciente Externa- No Hospitalizado
Ambos, durante esta estancia.
*
Fecha de Cita
*
Hora de la cita
*
Fecha de Entrada
*
Fecha de Salida
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Idioma principal
English
Arabic
Awadhi
Azerbaijani, South
Bengali
Bhojpuri
Burmese
Chinese, Gan
Chinese, Hakka
Chinese, Jinyu
Chinese, Mandarin
Chinese, Min Nan
Chinese, Wu
Chinese, Xiang
Chinese, Yue(Cantonese)
Dutch
French
German
Gujarati
Hausa
Hindi
Italian
Japanese
Javanese
Kannada
Korean
Maithili
Malayalam
Marathi
Oriya
Panjabi, Eastern
Panjabi, Western
Persian (Farsi)
Polish
Portuguese
Romanian
Russian
Serbo-Croatian, Serbian, Coation, Bosnian
Sindhi
Spanish
Sunda
Tamil
Telugu
Thai
Turkish
Ukrainian
Urdu
Vietnamese
Yoruba
Karen
Hungarian
ASL American Sign Language
Other
Chuukese
Nepali
Haitian-Creole
Somali
No se permiten apartados postales
Búsqueda postal de EE. UU. / Canadá
*
País
--Seleccione--
USA
Afghanistan
Aland
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos [Keeling] Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Curacao
Cyprus
Czechia
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar [Burma]
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
U.S. Minor Outlying Islands
U.S. Virgin Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
*
Dirección
Ciudad/Villa/Pueblo
Condado/Distrito
Estado/Provincia
Estado/Provincia
--Seleccione--
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
PR
Código postal
Información de contacto del guardián
Introduzca la información del tutor o tutores que se alojarán en RMHC.
*
Nombre del Tutor / Cuidador (Nombre y apellido)
*
Relación con el paciente
Patient
Mother
Father
Sibling
Grandparent
Relative
Friend of Family
Step-Parent
Parent's S.O.
Patient's S.O.
Unknown
Service Animal
Temporary Caregiver/Guardian
Nurse
Sexo del tutor
Varón
Hembra
Género no conforme
No binario
No nacido
Declinado
*
Fecha de nacimiento (MM/DD/AAAA)
*
Origen étnico
Seleccione una opción
Aboriginal
Arab/Middle Eastern
Asian
Black/African Descent
East Indian
First Nation
Hispanic
Latino
Maori
Multi-Racial
Native American or Alaskan native
Pacific Islander
White/Caucasian
Other
Declined
*
Correo electrónico principal
*
Número de teléfono principal
Acepto recibir mensajes de texto en este número.
You will receive a text from SlickText,
please respond YES to opt in
. Standard messages and data rates apply.
Nombre del Tutor / Cuidador (Nombre y apellido)
Relación con el paciente
Patient
Mother
Father
Sibling
Grandparent
Relative
Friend of Family
Step-Parent
Parent's S.O.
Patient's S.O.
Unknown
Service Animal
Temporary Caregiver/Guardian
Nurse
Sexo del tutor
Varón
Hembra
Género no conforme
No binario
No nacido
Declinado
Fecha de nacimiento (MM/DD/AAAA)
*
Origen étnico
Seleccione una opción
Aboriginal
Arab/Middle Eastern
Asian
Black/African Descent
East Indian
First Nation
Hispanic
Latino
Maori
Multi-Racial
Native American or Alaskan native
Pacific Islander
White/Caucasian
Other
Declined
Número de teléfono principal
Acepto recibir mensajes de texto en este número.
Please check this box if this number is able to receive text messages..You will receive a text from SlickText,
please respond YES to opt in
. Standard messages and data rates apply.
Additional Guest(s) Information
¿Habrá huéspedes adicionales en la casa durante su estancia? Por favor, introduzca su información a continuación (hermanos, tías, tíos, primos, etc.).
Invitados adicionales / miembros de la familia
*
Acepto recibir mensajes de texto en este número.
Agregar otro invitado
informacion adicional
*
descripción
*
Teléfono secundario
¿Tendrá un vehículo en las instalaciones?
Seleccione una opción
No
SÍ
*
Marca / modelo / descripción del coche
*
Estado
--Seleccione--
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
PR
*
numero de licencia
¿Cuál de estos describe el ingreso total de su hogar? (Nota: Esta información solo se usa para asegurar fondos para la Cámara).
Seleccione una opción
Less than $10,000
$10,000 to $24,999
$25,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $149,999
$150,000 and greater
Unknown
*
¿el paciente tiene Medicaid?
Seleccione una opción
No
SÍ
¿El paciente tiene Seguro Privado?
Seleccione una opción
No
SÍ
*
Medicaid Id (si no hay medicaid, escriba N/A)
*
Subdivisión de Medicaid
N/A
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevade
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Si es un seguro privado, ¿quién es su proveedor de seguros? (tipo N/A si no tiene seguro privado)
Si no hay otras habitaciones disponibles, ¿podría aceptar una habitación con solo 1 cama?
Seleccione una opción
No
SÍ
Solicitud de ayuda enviada
Ok
Make sure the information below is complete and correct and click submit. Someone from the Ronald McDonald House will contact you.
Nombre de la persona que completa este formulario
Nombre del Paciente (Primer nombre y Apellido)
Teléfono
Correo electrónico
Enviar
