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Buena Vista Regional Medical Center

Patient Pre-registration Form

Welcome to the Buena Vista Regional Medical Center Online Patient Pre-registration service. This form is to register for your upcoming tests or procedures.

Should you need assistance filling out this form-please call 712-732-4030 and ask for a registration clerk.
Please complete the following information as completely and accurately as possible. It should only take you a few minutes to complete this form.

Please remember that upon your arrival to Buena Vista Regional Medical Center you will need to stop at the registration desk. You will be asked to verify your registration information. A copy of your insurance card will be required and you will be asked to sign authorization forms.

* Today's Date
* Date of Admission/Procedure/Testing
Date that your test or procedure is scheduled.
* Ordering Physician
Who is the physician ordering the test or procedure you are pre-registering for?
* Family Physician
If no physician enter "None"
* Patient Last Name
* Patient First Name
* Patient Middle Initial
* Street Address
Full Physical Street Address
* Post Office Box
If you do not have one, please type "none"
* City
* State
* Zip Code
* County
* Telephone
Example 712.555.5555
  Cell Phone Number
Example 712.299.9999
* Date of Birth
* Marital Status Single     Married     Divorced     Widow     Separated    
* Sex Male     Female    
* Race Asian     Black     Caucasian     Hispanic     American Indian    
* Are You Employed? Yes     No    
  Employer's Name
If you are employed please list your major employer's business name.
  Employer's Street Address
  Zip Code
Five Digit Zip Code
  Employer Phone Number
Example 712.555.5555
  Retirement Date
* When Paying Healthcare Bills...How Do You Plan To Pay? Insurance     Cash     Medicaid     Medicare     Credit Card     Debit Card    
  Responsible Party Information
Fill Out Below If The Patient Is Not The Resonsible Party
If Patient Above Is Responsible Party Then Check This Box
  Person Responsible For Bill
  Date of Birth
  Social Security Number
Nine Digit Social Security Number 999-99-9999
  Street Address and/or P.O. Box
  Zip Code
Five Digit Zip Code
Example 712.555.5555
  Sex Male     Female    
  Relationship To Patient
  Employer's Name
If you are employed please list your major employer's business name.
  Employer's Street Address
Five Digit Zip Code
  Employer Phone Number
Example 712.555.5555
* Person To Notify In Case Of An Emergency
Please Type In Full Name, Relationship, Address, Area Code & Telephone Number. This should be someone living outside of your home.
  Primary Insurance Name
Example-Medicare, Medicaid, Wellmark, Cigna etc.
  Primary Insurance Company Address
If you have Medicare or Medicaid type "same"
  Primary Insurance Company Phone Number
Example 800.888.9999
  Primary Insurace Policy Holder Name
Type the name as it appears on your health insurance card.
  Policy Holder's Date of Birth
  Relationship to Patient Self     Spouse     Parent     Other    
  Primary Insurance Policy Number
  Primary Insurance Group Name and Number
Type "none" if there is not one
  Other Information
If your visit today is related to an injury. Please check one of the following.
Workers compensation     Auto accident     Other accident    
* Advance Directives
Do you have an Advance Directive that specifies your healthcare wishes in the event you are unable to tell us? Please bring a copy with you.
Living Will     Durable Power of Attorney     No I do not have either of these.    
* Allergies
Do you have allergies to medications, food, latex/rubber?
  If you checked YES to having allergies, please list those along with the reactions to the allergens.
* Are you a smoker? Current smoker     Former smoker     Never smoked    
* Your Primary Language
Please list.
* Do you need an Interpreter?
If you are bringing your own interpreter, please have that person be 18 years or older.
no     yes-please provide one for me     I will bring my own