Online Guest Stay Request - RMHC of Central Texas

GUEST REQUEST TO STAY ONLINE FORM

Complete your online request and click on SUBMIT.

Hospital Staff Only

1. Stay Request

Please enter the incoming family's expected arrival date. Please be aware that a background check must be completed prior to any guest arrival. Additionally, for both international and domestic families, confirmation of the check-in date and time needs to be confirmed by a Ronald McDonald House Charities staff member prior to arrival.

* Stay Location

* Arrival Date

* Estimated Departure Date

* # Occupants First Night

* English spoken at Home

Request completed by

2. Patient Information

* First Name

Middle Name

* Last Name

* Gender

* Date of Birth

* Ethnicity

* Diagnosis

* Facility Treated At

* Inpatient - Hospitalized

* Patient Care Unit

Add Another Patient

3. Guest Information: PLEASE, PLEASE ADD GUEST EMAIL. THANK YOU!

* First Name

Middle Name

* Last Name

* Gender

* Date of Birth

* Relationship to Patient

* Email

* Home Phone

* Mobile Phone

Type of Address

* Country

* Street 1

Street 2

* City

*State/Province

* Zip/Postal Code

*County

Add Another Guest

4. Additional Information: Please provide your NAME & PHONE NUMBER

* Family agrees to allow hospital to share info with RMHC CTX

* Language

* Patient has Medicaid

* Referral Contact Name

* Referral Contact Email

* Referral Contact Phone #

Notes regarding this request: Provide full name & DOB for other guests

Acceptance

Your request will be processed.

I confirm the patient family has been informed that some of their information will be shared by the hospital and given to RMHC CTX to secure services during their child's medical treatment.

I confirm the family has been informed background checks will be conducted on all guests aged 18 and older.

Do you want to continue?

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The following trademarks used herein are owned by McDonald's Corporation and its affiliates; McDonald's, Ronald McDonald House Charities, Ronald McDonald House Charities Logo, RMHC, Ronald McDonald House and Ronald McDonald Family Room.

GUEST REQUEST TO STAY ONLINE FORM

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