RMHC MCH Guest Registration Form

Patient's Name *

First

Last

For office purposes.

Father *

First

Last

If this section does not apply to your stay with us, simply enter N/A in the fields.

Father's Date of Birth *

Please enter as MM/DD/YEAR format (ex.: 07/16/2019)

Mother *

First

Last

If this section does not apply to your stay with us, simply enter N/A in the fields.

Mother's Date of Birth *

Please enter as MM/DD/YEAR format (ex.: 07/16/2019)

Patient's Name *

First

Last

Patient's Gender *

Male
Female

Patient's Date of Birth *

Please enter as MM/DD/YEAR format (ex.: 07/16/2019)

Patient's Social Security Number *

If patient is a newborn without an assigned SS#, enter N/A in this field.

Patient's Medicaid # *

If not yet available, please enter N/A in this field.

Patient's Medicaid Card Upload

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.

Patient's Name (multiples)

First

Last

If there are multiple patient's, please contact the office to complete your registration by calling 432-640-3090.

Mother's Social Security Number *

Mother's Medicaid # *

If you do not have medicaid, please enter N/A in this field.

Mother's Medicaid Card Upload

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.

Family Address *

Address Line 1

Address Line 2

City

State

Zip Code

County *

Primary Contact Phone *

Contact Email *

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.

Work Phone

Employer Name

Emergency Contact Name / Relationship to Patient *

Emergency Contact Number *

Patient's Hospital Physician *

Please indicate the name of the doctor overseeing the patient's current hospital stay. If unknown, enter N/A in this field.

Name of Referring Social Worker or Charge Nurse *

Patient's Diagnosis *

Guests staying in room (i.e. mom, dad, grandma, aunt, uncle, etc.): *

Enter name / relationship, separate multiple entries by commas (ex.: John Doe / grandfather, Mary Doe, grandmother, etc.) .

The following data is used only to assist RMHC in obtaining funds for our services and will not play a role in your eligibility status. It is safely collected data which is used for the charities funding purposes only. *

Please enter total number of family members living in your home in the space above.

Race / Ethnicity *

Check all that apply in your household.

Family's total annual income: *

Keeping families close

GUEST REGISTRATION