Volver al sitio web de Ronald McDonald House Charities of the Inland Northwest
Online Registration
Spokane
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Quién está completando este registro:
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Padre/tutor/cuidado
Trabajador social/personal del hospital
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¿Te has alojado con nosotros antes?
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No
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Continuar con el registro
¿Idioma preferido?
¿A quién cuidas?
Información del paciente:
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Nombre del paciente (Nombre y apellido)
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Fecha de nacimiento del paciente (MM/DD/AAAA)
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Sexo del paciente
Varón
Hembra
Género no conforme
No nacido
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
¿El paciente o tutor tiene seguro estatal?
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No
SÍ
Medicaid Id (si no hay medicaid, escriba N/A)
Subdivisión de Medicaid
The Nile Shriners
Community in Motion
EOCOO/ GOBHI Oregon
Hopelink
Montana Medicaid
MTM- Idaho
Paratransit
People for People
Private Pay
Shriners
Shriners Corporate
Special Mobility Services
If the family has private insurance, please add the provider and # if possible.
Motivo de la estancia
Allergy and Immunology
Behavioral and Developmental
Burn
Cardiology
Chemical Dependency
Critical Care
Dentistry
Dermatology
Diabetes
Digestive
Down Syndrome
Eating Disorder
Emergency Medicine (Injury/Trauma/Accident)
Gastroenterology and Hepatology
General Pediatrics and Adolescent Medicine
General/Day Surgery
Hematology and Oncology
High Risk Pregnancy
Hospital Employee
Infectious Diseases
Labor and Delivery
Mental Heath
Metabolic Disease
Mitochondrial Disease
Nephrology
Neurology
Newborn w/Complications
Ophthalmology
Orthopedics
Otolaryngology (ENT)
Outpatient Appointment
Pain Rehabilitation
Premature Infant
Pulmonology
Respiratory
Rheumatology
Seizures
Sleep Study
Substance Abuse
Transplant
Urology
Diagnóstico
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¿El paciente será será un paciente internado o ambulatorio?
Paciente Interno- Hospitalizado
Paciente Externa- No Hospitalizado
Ambos, durante esta estancia.
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Departamento
Adult ICU & CICU
Adult Psych
Cardiology
Child and Adolescent Psychiatry
Dentistry
Developmental and Behavioral
Doctor's Office
Emergency Department
Eye Clinic
Intermediate Nursery
Nephrology
Neurology
NICU
Oncology
Orthopedics
Outpatient
Palliative Care
Pediatric Endocrinology Clinic
Pediatrics
Peds Digestive Health/ Gastroenterology
Peds Intermediate
PICU
Pulmonary
Rehabilitation
Respiratory
Sleep Lab
Urology
Other
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Paciente está siendo tratado en:
Beacon Cancer Care
Cancer Care NW
Co-Treatment - Cancer Care NW & KH Cancer Clinics
Daybreak Treatment Facility
Deaconess Medical Center
Empire Therapy
Inland Northwest Behavioral Health
KH Cancer Clinics
Kootenai Health
North Idaho Eye Institute
Northern Idaho Advanced Care Hospital (NIACH)
Northwest Pediatric Ophthalmology
Providence Holy Family
Sacred Heart Medical Center
Shriners
Spokane Eye Clinic
Spokane Pediatric Dentistry
St. Luke's
Tamarack Treatment Center
Treasure Valley Neurotherapy
University Hearing & Speech Clinic (EWU/WSU)
Other
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Trabajador social
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Not Assigned
Sue Ellen
Jessica (Jachetta)
Other (Staff Indicate)
Kelsi Adams
Ashlee Ahlrich
Cassie Anderson
Lucy Anderson
Mel Bambock
Lionel Barajas Palomino
Annette Barfield
Heidi Bishop
Kelly Brajcich
Tina Broadsword
Fay Cadwallader
Heather Carroll
Heidi Casebier
Alicia Casserino
Juli Clay
Denise Conrad
Leon Covington
Molly Crumet
Kinzie Davidson
Julie Dubois
Andrea Durst
Heather Emch-Bettesworth
Linda Evans
Mindy Fay
Patty Ferguson
Chelsey Fleishman
Travis Geib
Adie Goldberg
Kaylyn Grams
Janelle Green
Annie Halstead
Kelly Hawley
Emily Hibbs
Amber Huwe
Kim Jones
Laurel Kelly
Jill Kuisti
Chelsea Kulisek
Svetlana Kuropatko
Angie LaBreck
Linda Leonard
Madeleine Lewis
Gail Mahoney
Kameron Manley
Jacqueline (Jaye) Marcus-Ledford
Rachel Marko
Christy McAnally
Mirranda McVay
Kristina Mertz
Tricia Mettler
Denise Metzger
Teri Mindermann
Sara Mitchell
Lara Munden-Johnson
Danelle Neep
Angela Newburn
Brenda Olson
Brandon Owen
Zoie Patch
Yolanda Pfaff
Andrea Popp
Keegan Potesky
Janice Ramirez
Rebecca Reid
Brandy Rex
Marilyn Rich
Esther Rios
Agnes Roberts
Laura Robinson
Lora Ross
Justin Schorzman
Kayla Sheperd
Katie Swain
Christopher Swenson
Janelle Taylor
Riley Thompson
Jessica Van Boven (Jachetta)
Tammy Wall
Lisa Way
Amanda Williamson
Catherine Wolf
Darren Woods
Staci Wright
Other
¿Quién se hospedará en RMHC INW?
Parent/Guardian Information:
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Nombre del Tutor / Cuidador (Nombre y apellido)
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Relación con el paciente
Patient
Mother
Father
Grandparent
Relative
Friend of Family
Step-Parent
Parent's Significant Other
Unknown
Aunt/Uncle
Sibling
Foster Parent
Adoptive Parent
Great Grandparent
Spouse
Child of Patient
Hospital Employee
Niece/Nephew
Patient's Significant Other
Son/Daughter In-Law
Grandchild
Great Grandchild
Sibling In-Law
Número de teléfono principal
Correo electrónico principal
Búsqueda postal de EE. UU. / Canadá
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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
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Singapore
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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
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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
Fecha de nacimiento (MM/DD/AAAA)
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Sexo del tutor
Varón
Hembra
Género no conforme
No nacido
Origen étnico
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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
Información del segundo padre/tutor:
*
Relación con el paciente
Patient
Mother
Father
Grandparent
Relative
Friend of Family
Step-Parent
Parent's Significant Other
Unknown
Aunt/Uncle
Sibling
Foster Parent
Adoptive Parent
Great Grandparent
Spouse
Child of Patient
Hospital Employee
Niece/Nephew
Patient's Significant Other
Son/Daughter In-Law
Grandchild
Great Grandchild
Sibling In-Law
Nombre del Tutor / Cuidador (Nombre y apellido)
Número de teléfono principal
Correo electrónico principal
Fecha de nacimiento (MM/DD/AAAA)
*
Sexo del tutor
Varón
Hembra
Género no conforme
No nacido
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
Invitados adicionales / miembros de la familia
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Agregar otro invitado
¿Cuándo podemos esperarte?
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Fecha de Entrada
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Fecha de Salida
¿Acomodaciones especiales u otra información que debamos saber? (por ejemplo: discapacidad auditiva, se requiere accesibilidad según la ADA, etc.)
Solicitud de ayuda enviada
Ok
Nombre de la persona que completa este formulario
Nombre del Paciente (Primer nombre y Apellido)
Teléfono
Correo electrónico
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