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Patient Pre-Registration Application

Patient Pre-registration Application
This form is to register for our Patient Pre-registration Program. You will still need to stop by Registration, located in the main lobby, when coming to our Facility for services. By completing the on-line form you can reduce your registration time and receive peace of mind that we have your medical information.
ALL FIELDS IN RED ARE REQUIRED FIELDS.
Please complete the following items. This form should take 4 or 5 minutes to complete.
Personal Information
Last Name:
First Name:
Middle Initial:
Date
Mar-11-2010
Social Security Number:
Current Address:
Current City:
Current State:
Current Zip:
Day Time Telephone:
Night Time Telephone:
Ordering Physician:
Procedure Date:
 /  / 
Date of Birth:
 /  / 
Marital Status:
SingleMarriedDivorced
Sex:
MaleFemale
Race:
BlackWhite AsianIndian
Religion:
Are you currently employed?
yesno
Work History
Current or Most Recent Employment
Employer Name
Address
City
State
Zip
Phone Number

Job Position(s)
PRNFull Time
Part Time

Retirement Date
 /  / 

When Paying Healthcare Bills...How Do You Plan To Pay?
InsuranceCash MedicaidMedicare
Responsible Party Information
Fill Out Below If The Patient Is Not The Responsible Party
If Patient Above Is Responsible Party Then Check This Box
Last Name:
First Name:
Middle Initial:
Relationship to Patient:
Social Security Number:

Birth Date
 /  / 

Phone Number
Current Address:
Current City:
Current State:
Current Zip:
Sex:
MaleFemale
Employer Name
Address
City
State
Zip
Phone Number

Job Position(s)
PRNFull Time
Part Time
Emergency Contact Information

Emergency Contact's Full Name
Current Address:
Current City:
Current State:
Current Zip:
Phone Number
Relationship To Patient
Insurance Information
Name of Insurance
Please Include the Name of Your Primary and Secondary Insurance (i.e. Medicare, Medicaid, United Heathcare)
Insurance Number

Include Insurance Number and Group Number
Effective Date of Primary Insurance
 /  / 
Policy Holder If Other Than Patient
Policy Holder Date of Birth
 /  /