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Pre-Registration
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Patient Information
- 2
Payment Information
- 3
Patient Information
- 4
Review
Appointment Details
Note: This is not a request for a new appointment. Please enter a scheduled appointment date and time for a surgery, test, procedure or physician office visit.
Appointment Date
Time (Hour:min)
Patient's Full Legal Name
First
Middle
Last
Suffix
Contact Information
Phone Check the boxes bellow if we may leave messages at this number
Home
Work
Email
Communication Preferences
Out of the following, please rank how you would prefer we contact you from your most (top) to least (bottom) favorite. Drag items up and down or use the arrows to put them in order.
Home Address
Address 1
Address 2
City
State
ZIP Code
Country
May we send mail to this address?
Gender
Date Of Birth
Last 4 digits of security number
Marital status
We ask you to tell us your race, ethnicity and preferred language so that we can review the treatment that all patients receive and make sure that everyone gets the highest quality of care. This information will only be used for perfomance improvement and the confidentiality of what you say is protected by the law.
Hispanic or Latino Origin
Race
Preferred language
Religious Preference
Employement Status
Emergency Contact
First Name
Last Name
Please enter a home or cell phone number
Home Phone
Cell Phone
Relationship to Patient
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Insurance Information
Is the patient having these services performed as a result of Injury or Accident?
Are you eligible for Medicare?
Is this service covered by insurance?
Health Plan 1
Health Plan Type
Name of Health Plan
Employer Name
Group Number
Member ID Number
Medical Group
Health Plan Billing/Claims Address
Address 1
Address 2
City
State
ZIP Code
Phone
Subscriber Information
Subscriber relationship to patient
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Procedure and Serivce Information
Service Type
Reason for visit
Ordering Physican First Name
Ordering Physican Last Name
Primary Care Physician
First Name
Last Name
Would you like to receive additional information about MCH programs and services related to this admission?
May the hospital share information about your location in the facility and general condition with visitors and called?
Do you have a signed Power of Attorney on file?
Do you have an Advance Directive and a Durable Power of Health Care?
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Review
Appointment Details
Appointment Date: 02/21/2021
Time (Hour:min): 9:00 AM
Patient's Full Legal Name
First: John
Middle: Bill
Last: Doe
Suffix: N/A
Contact Information
Home: 000-000-0000
Cell: 000-000-0000
Work: 000-000-0000
Email: test@test.com
Communication Preferences
Value1
Home Address :
Address 1: Address 1
Address 2: Address 2
City: City
State: CA
ZIP Code: CA
Country: US
May we send mall to this address? Yes
Gender: Male
Date Of Birth: 10/02/1995
Last 4 digits of security number: 1234
Marital status: Single
Hispanic or Latino Origin: Yes
Race: Value
Prefered language: English
Religious Preference: Church of Christ
Employement Status: Full time
First Name: John
Last Name: Doe
Please enter a home or cell phone number
Home Phone: 000-000-0000
Cell Phone: 000-000-0000
Relationship to Patient: Father
Insurance Information
Is the patient having these services performed as a result of Injury or Accident? Yes
Are you eligible for Medicare? Yes
Is this service covered by insurance? Yes
Procedure and Serivce Information
Service Type: N/A
Reason for visit: N/A
Ordering Physican First Name: N/A
Ordering Physican Last Name: N/A
Primary Care Physician
First Name: N/A
Last Name: N/A
Would you like to receive additional information about MCH programs and services related to this admission? Yes
May the hospital share information about your location in the facility and general condition with visitors and called?
Do you have a signed Power of Attorney on file? Yes
Do you have an Advance Directive and a Durable Power of Health Care? Yes
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