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Bacon County Hospital

Online Pre-Registration

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.
* First Name
Enter the patient's First Name.
* Last Name
Enter the patient's Last Name.
* Address
  Apt/Lot #
* City
* State
* Zip Code
* County
* Telephone Number
Enter area code with phone number: (000)-000-0000
* Date of Birth
Enter using this format: mm/dd/yyyy
* Social Security Number
* Sex FEMALE
MALE
* Race
* Religion
  Marital Status SINGLE
MARRIED
DIVORCED
SEPARATED
WIDOW
  Spouse Name
Please enter the spouse's full name. Put N/A if single or widowed.
  Patient Employer
Enter the company name here. Put N/A if unemployed.
* 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
  Father's Name
  Mother's Name
* Emergency Contact Name
* Emergency Contact Address
* Emergency Contact Telephone Number (Home)
Please provide the area code and phone number: (000)-000-0000
  Emergency Contact Phone Number (Work/Cell)
Please enter area code and phone number: (000)-000-0000.
* Primary Insurance Company Name
Please enter the name of your insurance company here (Example: Blue Cross). If you do not have insurance, put NONE.
  Insurance Company Address
Put the mailing address of your insurance company here, if known.
  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.
  Insurance Holder Name
To whom is the insurance policy issued?
  Patient Relationship
How is the patient related to the insurance policy holder?
Self
Spouse
Son
Daughter
Other
  Insurance Policyholder Birthdate
Enter the policyholder's date of birth (ex. mm/dd/yyyy).
  Insurance Policy Number
  Insurance Group Name or Number
  Supplemental Insurance
Please enter the name of your insurance company here (Example: Blue Cross). If you do not have insurance, put NONE.
  Insurance Company Address
Put the mailing address of your insurance company here, if known.
  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.
  Insurance Holder Name
To whom is the insurance policy issued?
  Patient Relationship
How is the patient related to the insurance policy holder?
Self
Spouse
Son
Daughter
Other
  Insurance Policyholder Birthdate
Enter the policyholder's date of birth (ex. mm/dd/yyyy).
  Insurance Policy Number
  Insurance Group Name or Number
* 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.
* Physician Ordering Test/ Procedure or Surgery
* Procedure/Test