Online Guest Stay Request

ROOM REQUEST ONLINE FORM

Complete your online request and click on SUBMIT.



1. Stay Request


2. Patient Information



* 1. Name of Person Making Referral

* 2. Title of person making referral

* 3. Phone number of person making referral

4. Email address of person making referral

* HOSPITAL DEPARTMENT

* Physician

* Refer Agency



3. Guest Information



* 1. Is there any reason the guest would not be appropriate for Ronald McDonald House?

* 2. Does the guest have a current Child Protective Services investigation or previous conviction?

* 3. Is the guest a registered sex offender or currently under investigation for a sex-related crime?

* 4. Is the guest under investigation for or previously convicted of a violent offense?

* 5. Does the guest have any current pest infestation? If so, guest is not eligible for admission

* 6. Is the guest a carrier of any infectious illness? If so, guest may not be eligible for admission. Please detail below.




4. Additional Information

* 1. Has the family tested positive for COVID-19?

* 2. Has the family been around anyone with confirmed or suspected COVID-19?

* 3. Has the family been in self-isolation for 14 days or more?, or

* 4. Has the family been at patient bedside for 14 days or more?, or

* 5. Is the family from a region with declining incidence of COVID-19?

* 6. Does the family agree to wear masks, wash hands frequently, maintain social distancing, submit to temperature checks, and other COVID-19 related requirements?

* 7. Does the family understand that common rooms are not accessible, visitors are not allowed, and guests may not return home during their stay and may not rotate with other family members?


Notes regarding this request:



Acceptance

Your request will be processed. Do you want to continue?



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