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Cameron Memorial Community Hospital

Patient Online Pre-Registration

This form is to register for our Patient Pre-registration Program. By registering with us you can receive peace of mind that we have accurately received a good portion of your medical information prior to your actual hospital check-in and registration, and make your hospital registration easier and faster!

This form should be completed and submitted to Cameron Hospital at least
72 hours prior to your anticipated hospital arrival.

Upon arrival for your procedure, please check in to Cameron's Express Check-In. Also, bring your physician's order with you when you arrive for your procedure.
Please Print clearly and Complete the following information. This form should take 4 or 5 minutes to complete.

* Indicates a Required Field.
PATIENT INFORMATION:
* Name
First Name, Middle Initial, Last Name, Suffix
* Family Physician
* Ordering Physician
* Date of Procedure
* Procedure
Please select the reason for your visit.
Lab     Xray     Other    
  Other
If Other, please indicate procedure here.
* Street Address
Full Street Address or P.O. Box
* City
* State
* Zip Code
* Telephone
Include Area Code
* Date of Birth
* Marital Status Single     Married     Divorced     Widowed    
* Sex Male     Female    
* Race African American     Caucasian     Asian     Indian     Hispanic     Other    
* Social Security Number
EMPLOYMENT INFORMATION:
* Are You Employed? Yes     No    
  Employer's Name
  Employer's Street Address
  City
  State
  Zip Code
  Employer Phone Number
Include Area Code
  Retirement Date
(Medicare Patients Only)
RESPONSIBILITY FOR PAYMENT:
* Is Patient Responsible for Payment? Yes     No    
If Patient is Not the Responsible Party Fill in the Information Below:
  Other Person Responsible for Payment
  Date of Birth
  Street Address or P.O. Box
  City
  State
  Zip Code
  Telephone
Include Area Code
  Sex Male     Female    
  Relationship to Patient
  Social Security Number
  Employer's Name
INSURANCE INFORMATION:
  Enter Patient Insurance Information:
Include Primary and Secondary Insurance Numbers, Group Number and Phone Number of Insurance Company.
EMERGENCY CONTACT:
* Person to Notify in Case of an Emergency
Enter Full Name, Relationship, Address, Area Code & Telephone Number