Request A Room | Ronald McDonald House Charities Fargo

Have You Stayed With Us Before*

Patient Name*

Diagnosis*

Care Facility*

Patient Date of Birth*

Transportation Needed*

Handicap Accessibility Needed*

Date Room Needed

Numbers of Adults Staying*

(1) Adult Name*

(First, Middle Last)

(1) Adult Date of Birth*

(Day, Month, Year)

(2) Adult Name*

(First, Middle Last)

(2) Adult Date of Birth*

(Day, Month, Year)

(3) Adult Name*

(First, Middle Last)

(3) Adult Date of Birth*

(Day, Month, Year)

(4) Adult Name*

(First, Middle Last)

(4) Adult Date of Birth*

(Day, Month, Year)

(5) Adult Name*

(First, Middle Last)

(5) Adult Date of Birth*

(Day, Month, Year)

Numbers of Children Staying*

(1) Child's Name*

(First, Last)

(1) Child's Date of Birth*

(Day, Month, Year)

(2) Child's Name*

(First, Last)

(2) Child's Date of Birth*

(Day, Month, Year)

(3) Child's Name*

(First, Last)

(3) Child's Date of Birth*

(Day, Month, Year)

(4) Child's Name*

(First, Last)

(4) Child's Date of Birth*

(Day, Month, Year)

(5) Child's Name*

(First, Last)

(5) Child's Date of Birth*

(Day, Month, Year)

Patient Relationship

Physical Address*

Street Address Address Line 2 City State ZIP Code

Mailing Address

If different from above address

Street Address Address Line 2 City State ZIP Code

Preferred Phone*

Email

Guest Health Screening
Please answer YES or NO to all of the questions below.

Have you had any of the following:

Fever higher than 100.4F (38C) in the past 72 hours?*

Yes
No

Vomitting in the past 2 days?*

Yes
No

Stiff neck or headache with a fever in the past 2 days?*

Yes
No

Diarrhea in the past 2 days?*

Yes
No

Current skin lesions that are "weepy" (fluid or pus-filled)?*

Yes
No

ANY current skin rash?*

Yes
No

Current cold or flu symptoms (runny nose, cough, congestion)?*

Yes
No

Exposure to Tuberculosis (TB) in the past 2 months?*

Yes
No

Exposure to any of the following within the past 3 weeks:*

Yes
No

Chickenpox
Measles
Mumps
Whooping Cough

CORONAVIRUS RELATED HEALTH QUESTIONS

Do you have a fever, chills, sore throat, cough, new onset of shortness of breath, new onset loss of taste or smell, or new onset muscle pain, or have a pending COVID-19 test because you were having any of these symptoms?*

Yes
No

Do you have a pending COVID-19 test without any of the symptoms previously mentioned?*

Yes
No

In the last 14 days, have you been exposed to anyone with a lab confirmed COVID-19 test or have you had a COVID-19 positive test results?*

Yes
No

Have you been told by a healthcare provider or public health official that you should self-quarantine due to potential COVID-19 exposure?*

Yes
No

Permission to Complete a Background Check*

Comments

This field is for validation purposes and should be left unchanged.