Hospital Preregistration Form

Denotes required fields
Which facility will you be visiting?

Patient Information

Address
Do you have an email address?
Do we have your permission to tell your church that you are here today? This means they will be given your name when they visit.

Patient Employment Information

Address

Spouse Information

Address

Spouse Employment Information

Address

Emergency Notifications

Emergency Notification 1

Emergency Notification 2

Patient Representative for this Visit

Your patient representative is the person you have selected to receive information from our staff regarding your care.
Have you appointed a patient representative?

Financially Responsible Party

Who is financially responsible for this visit?
Address

Insurance Information

Coinsurance payment may be requested at the time of registration.

Insurance Statement

Do you have medical insurance?
Are you the subscriber?
Address
Address
Subscriber’s Address if Different From Patient’s
Address
Are you eligible to receive Medicare benefits?
Do you have secondary coverage?
Are you the subscriber?
Address
Address
Subscriber’s Address if Different From Patient’s
Address

About Your Condition

Procedure Information

Are you scheduled for any other procedures?