The code block below illustrates how one might use # and // as comments in your logic and calculations.

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The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

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Required format:

qt2iuPiCqdyd4ma7IKdt2HCfx5zHN4R5WXUKu5E9QiLpFHsHW2x2RKhFoEY

Ronald McDonald Care Mobile Scheduling Request

What is your preferred language?

* must provide value

English

Spanish

Other

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If other is selected for preferred language, please indicate below what language.

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Thank you for your choosing the Ronald McDonald Care Mobile. Please complete the questions below to indicate your availability. This pre-registration survey is multiple pages, please be sure to complete all of the pages in order to be seen.

Disclaimer: ALL Pre-registrations especially those for Vaccines/ Immunizations need completed 48hrs prior to the scheduled clinic day.

Are you the child's legal guardian?

* must provide value

Yes

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If you are not the patient's legal guardian, what is your relationship to the patient?

* must provide value

What is the child's mother's maiden name?

* must provide value

Please provide the parent or guardians first and last name.

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Please provide the parent or guardians date of birth.

* must provide value

What is the child's first and last name?

* must provide value

Child's date of birth

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M-D-Y

What is the child's age?

* must provide value

What is the child's sex assigned at birth?

* must provide value

What is your mailing address?

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What is your zip code?

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What is your contact number?

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What is your email address?

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What school does your child attend?

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Please choose your preferred day/location for a Clinic Day Appointment:

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Please choose your preferred day/location for a Clinic Day Appointment:

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Please choose your preferred day/location for a clinic day appointment:

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Disclaimer: Please arrive well in advance of the ALL clinic end times. The Care Mobile Team will end 30 minutes prior to the cut off time for breakdown preparations. Please arrive no later than an hour prior to cut off time.

Please choose your preferred day/location for a clinic day appointment:

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Has your child had a visit within the past 2 years with their primary care doctor?

* must provide value

Yes

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What service would you prefer for the Clinic Day?

* must provide value

Asthma

Sports Physical

Vaccine/Immunizations

Hearing and Vision Screening (3300 Form)

Health Checks (ONLY Ages 3-10 years)

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Disclaimer: The Ronald McDonald Care Mobile does not accept insurance from Kaiser, SSI Medicaid, United Healthcare, and Tri-Care. Should you care to proceed still with the services, please be aware you will receive a bill in the mail.

Does your child have insurance?

* must provide value

Yes

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Does your child have a primary care physician?

* must provide value

Yes

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Please provide your child's primary care physicians name.

* must provide value

At the last visit was your child sick or well?

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When was the last time your child was seen at the dentist?

* must provide value

If the flu vaccine were available, would you be interested?

Yes

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If the COVID vaccine were available would you be interested?

Yes

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.