Guest Referral

Guest Referral Form

This referral can be submitted up to 30 days in advance of any scheduled appointment.This referral does not automatically guarantee eligibility or room availability. Phone Number: (850) 477.2273
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Medicaid Patient ID #
Medical Facility
Doctor Providing Care
Diagnosis
Reason for Visit:
Is this referral for a stay at our House location or Family Room?

Ronald McDonald HouseRMH Family Room
Prior to selecting a guest room below, please ensure room avaiblity with the House Supervisor or Social Worker on duty.
Please assign guest a room

Room 1 (Closest to Guest Computers)Room 2 ( Middle)Room 3 ( Closest to Exit )
Check- In Date

MonthDayYear
Date
Upload a copy of guest staying overnight valid government-issued ID to confirm your identity (e.g., driver's license, passport,etc.)
Admission or Appointment Date

MonthDayYear
Date
Anticipated Length of Treatment
Referring Staff Contact Number
Referring Staff Name
Primary Parent/Legal Guardian

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Contact Number
Notes
Example: Multiple patients, Adoptive family, Child discharged, Traveling from afar, Etc.
Should be Empty:

Guest Referral Form