Online Guest Stay Request - RMHC San Antonio

GUEST REQUEST TO STAY

Complete your online request and click on SUBMIT.

Referral must be completed and

submitted by Hospital Social Worker,

Charge Nurse or other medical personnel

Medical Center RMH- Serving all of San Antonio

CHOSA - Serving CHOSA patient's only

1. Stay Request

Qualifications Verified by RMHC

Patient is 21 years or younger
# of Miles Patient is from Medical Facility (must be more than 20)
High risk pregnancy patient must be accompanied by an adult in room
ID Required for Background Check for all 18 and older
Only 4 Individuals per room
This form is not a guarantee of room

* Stay Location

* Arrival Date

* Estimated Departure Date

2. Patient Information

* First Name

Middle Name

* Last Name

* Date of Birth

* Diagnosis

* Hospital/Clinic

* Is Patient Hospitalized?

* Physician

Family Emergency Contact

Family Emergency Phone

Relation to Patient

* Medical Professional Making Referral

* Referred By Title

Social Worker/Medical Provider Email

* Social Worker/Medical Provider Telephone

Add Another Patient

3. Guest Information

* First Name

Middle Name

* Last Name

* Date of Birth

* Relationship to Patient

Home Phone

* Mobile Phone

* Country

* Street 1

Street 2

* City

*State/Province

* Zip/Postal Code

County

Add Another Guest

4. Additional Information

Spanish Speaking Only

Notes regarding this request:

Acceptance

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

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Ronald McDonald House Charities of San Antonio
4847 Charles Katz Drive
San Antonio, TX 78229
Phone: (210) 580-9000
Email: info@rmhcsanantonio.org

Refund Policy

GUEST REQUEST TO STAY

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