Room request
* Patient Last Name
* Patient First Name
* Patient Date of Birth (MM/DD/YYYY)   or Unborn
* Gender
* Has the patient stayed at RMH Stanford before?
* Parent/Guardian's Name(s)
Please include the names and relationships of all adults to be residing at RMH.
Name Relationship
Siblings
Please include the name, age, and gender of all siblings to be residing at RMH.
Name Age Gender
* Street Address
* City/State /
County/Province
* Zip/Postal Code
* Country
* Home Phone
Cell Phone
Other Phone
Email
* Clinical Service
Diagnosis
* Requested Check-In Date
(Please understand that RMH Stanford runs at full capacity. Our goal is to be able to provide a room for every family. However, we are not always able to accommodate requests. By submitting your Housing Request, you will enable us to track your housing needs throughout the duration of your hospital visit.)
* Approximate Check-Out Date
(We understand that, in many cases, your check-out date is unknown. However, please give us your best estimate. You may revise your check-out date at a later stage, if necessary)
* Number of Guests Adults    Children
(Fire and Safety Code stipulates a maximum occupancy of 4 guests per room.)
* Name of the hospital at which the child will be treated
* Will the child be an in-patient at the hospital, out-patient (staying at RMH), or some combination?
Purpose of Visit
Form of Payment
* Will you have access to a car?
* Social Worker Name
Special Needs (please check all that apply) Crib / Pack 'n Play
Other Language
Wheel Chair Access
Need Bath Tub
No Stairs
Heart/Lung Transplant Wing
Bone Marrow / Stem Cell Transplant Wing
Other
Please provide us with any other information relevant to your Housing Request
Please enter the following security code: