GUEST REGISTRATION

For office purposes.
If this section does not apply to your stay with us, simply enter N/A in the fields.
Please enter as MM/DD/YEAR format (ex.: 07/16/2019)
If this section does not apply to your stay with us, simply enter N/A in the fields.
Please enter as MM/DD/YEAR format (ex.: 07/16/2019)
Please enter as MM/DD/YEAR format (ex.: 07/16/2019)
If patient is a newborn without an assigned SS#, enter N/A in this field.
If not yet available, please enter N/A in this field.
Click or drag a file to this area to upload.
If the patient has Medicaid, take a photo of the card and upload here for our records. This is a secure upload and will be kept securely in our files at RMHC.
If there are multiple patient's, please contact the office to complete your registration by calling 806-744-8877.
If you do not have medicaid, please enter N/A in this field.
Click or drag a file to this area to upload.
If the mother has Medicaid, take a photo of the card and upload here for our records. This is a secure upload and will be kept securely in our files at RMHC.
Email is a very easy way for us to stay connected to the families in the House. Please include the email address that you most regularly check.
In the event that your vehicle requires attention while in the RMHC parking lot, we will need your vehicle information. If you will not have a vehicle during your stay with us, enter N/A in this field.
Enter N/A if no vehicle will be present during your stay at RMHC.
Please indicate the name of the doctor overseeing the patient's current hospital stay. If unknown, enter N/A in this field.
Enter names/ages separated by commas. (ex.: Jane Doe/8, Mary Doe/3, Sally Doe/1) Enter N/A if this section does not apply to you.
Enter names/ages separated by commas. (ex.: John Doe/11, Jim Doe/6, Alex Doe/4) Enter N/A if this section does not apply to you.
Enter name / relationship, separate multiple entries by commas (ex.: John Doe / grandfather, Mary Doe, grandmother, etc.) . Enter N/A if this section does not apply to you.
Please enter total number of family members living in your home in the space above.
Check all that apply in your household.