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Welcome to the online pre-registration service area. |
Thank you for using our pre-registration service. The information submitted here will allow us to start the registration process prior to your arrival for your test or procedure, thus saving time on your service day. Please fill in all of the blanks marked with an asterisk. If you have any questions, please call our admissions department at 632-8961 ext. 1095 or 2311. |
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First Name Enter the patient's First Name. |
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Last Name Enter the patient's Last Name. |
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Address |
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Apt/Lot # |
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City |
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State |
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Zip Code |
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County |
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Telephone Number Enter area code with phone number:
(000)-000-0000 |
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Date of Birth Enter using this format: mm/dd/yyyy |
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Last 4 Digits of Social Security Number Last 4 Digits of Social Security Number |
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Sex |
FEMALE MALE
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Race |
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Religion |
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Marital Status |
SINGLE MARRIED DIVORCED SEPARATED WIDOW
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Spouse Name Please enter the spouse's full name. Put N/A if single or widowed. |
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Patient Employer Enter the company name here. Put N/A if unemployed. |
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Parent Information Is the patient under 18 years of age? If yes, please answer the next 2 questions. If no, skip down to Emergency Contact. |
NO YES
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Father's Name |
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Mother's Name |
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Emergency Contact Name |
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Emergency Contact Address |
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Emergency Contact Telephone Number (Home) Please provide the area code and phone number: (000)-000-0000 |
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Emergency Contact Phone Number (Work/Cell) Please enter area code and phone number: (000)-000-0000. |
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Primary Insurance Company Name Please enter the name of your insurance company here (Example: Blue Cross). If you do not have insurance, put NONE. |
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Insurance Company Address Put the mailing address of your insurance company here, if known. |
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Insurance Company Telephone Number Please enter the telephone number of your insurance company. This number may be on the back of your insurance card. Enter the area code and phone number: (000)-000-0000. |
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Insurance Holder Name To whom is the insurance policy issued? |
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Patient Relationship How is the patient related to the insurance policy holder? |
Self Spouse Son Daughter Other
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Insurance Policyholder Birthdate Enter the policyholder's date of birth (ex. mm/dd/yyyy). |
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Insurance Policy Number |
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Insurance Group Name or Number |
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Supplemental Insurance Please enter the name of your insurance company here (Example: Blue Cross). If you do not have insurance, put NONE. |
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Insurance Company Address Put the mailing address of your insurance company here, if known. |
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Insurance Company Telephone Number Please enter the telephone number of your insurance company. This number may be on the back of your insurance card. Enter the area code and phone number: (000)-000-0000. |
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Insurance Holder Name To whom is the insurance policy issued? |
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Patient Relationship How is the patient related to the insurance policy holder? |
Self Spouse Son Daughter Other
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Insurance Policyholder Birthdate Enter the policyholder's date of birth (ex. mm/dd/yyyy). |
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Insurance Policy Number |
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Insurance Group Name or Number |
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Expected Date of Admission Enter the expected date of this visit or procedure (ex. mm/dd/yyyy). Contact your physician for this information if necessary. |
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Physician Ordering Test/ Procedure or Surgery |
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Procedure/Test |
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