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Stay With Us > Email Referral Form
Email Referral Form
Patient Name *
Patient Birthdate *
New
Returning
Social Worker
Medical Transport
Physician
Date of Arrival *
Number of Nights *
Hospital *
Diagnosis *
Doctor's Name *
Doctor's Phone *
Inpatient
Outpatient
Parent/Guardian Name *
language
communication difficulties
family dynamics problems
underage parents
Additional issues
Please be aware, and make families aware, of the following rules regarding stays at RMH-Dallas:
1) All guests over 18 years of age will be required to show acceptable, current photo ID to stay at RMHD.2) Only family members directly involved in the care of the child may stay at RMHD.3) Rooms are limited to a maximum of five people, regardless if the guests are adult or children.
Notes
