Guest Stay Online Request - Fundación Infantil Ronald McDonald Puerto Rico

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Stay Request

Para ser completado por un trabajador social o un profesional de la salud

Si esta es una solicitud de extensión de estadía, HAGA CLIC AQUÍ

1. Stay Request

* Stay Location

* Arrival Date

* Estimated Departure Date

* # Occupants First Night

Request completed by

Otro

* Social Worker

Social Worker Alternate Phone

Social Worker Alternate Email

2. Patient Information

3. Guest Information

Ingrese los detalles de TODOS los invitados aquí (máximo 4). Donde dice Apellido, ingrese ambos apellidos. Por favor, no utilice guiones, símbolos ni acentos.

* First Name

Middle Name

* Last Name

* Gender

* Date of Birth

* Relationship to Patient

* Email

Home Phone

* Mobile Phone

* Country

* Street 1

Street 2

* City

*State/Province

* Zip/Postal Code

County

Add Another Guest

4. Additional Information

* 1. Has family stayed before?

Yes

2. The Family Suffered/Suffers any of the following:

Minors Abuse

Domestic Violence

High Risk Pregnancy

Ilicit Cases

Contagious Diseases (Chicken Pox, Meningitis, Conjuntivitis, Flu, etc.)*

If you chose Contagious Diseases, please specify here.

Notes regarding this request:

Acceptance

Su solicitud será procesada. ¿Quiere continuar?

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Fundación Infantil Ronald McDonald Puerto Rico
250 Calle Convento
San Juan, PR 00912
787.384.7825
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