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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.
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PATIENT INFORMATION: |
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Name First Name, Middle Initial, Last Name, Suffix |
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Family Physician |
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Ordering Physician |
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Date of Procedure |
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Procedure Please select the reason for your visit. |
Lab Imaging Services Other |
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Other If Other, please indicate procedure here. |
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Street Address Full Street Address or P.O. Box |
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City |
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State |
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Zip Code |
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Telephone Include Area Code |
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Date of Birth |
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Marital Status |
Single Married Divorced Widowed |
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Sex |
Male Female |
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Race |
African American Caucasian Asian Indian Hispanic Other |
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Last 4 Digits of Social Security Number Last 4 Digits of Social Security Number |
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EMPLOYMENT INFORMATION: |
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Are You Employed? |
Yes No |
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Employer's Name |
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Employer's Street Address |
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City |
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State |
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Zip Code |
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Employer Phone Number Include Area Code |
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Retirement Date (Medicare Patients Only) |
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RESPONSIBILITY FOR PAYMENT: |
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Is Patient Responsible for Payment? |
Yes No |
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If Patient is Not the Responsible Party Fill in the Information Below: |
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Other Person Responsible for Payment |
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Date of Birth |
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Street Address or P.O. Box |
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City |
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State |
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Zip Code |
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Telephone Include Area Code |
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Sex |
Male Female |
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Relationship to Patient |
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Last 4 Digits of Social Security Number Last 4 Digits of Social Security Number |
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Employer's Name |
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INSURANCE INFORMATION: |
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Enter Patient Insurance Information: Include Primary and Secondary Insurance Numbers, Group Number and Phone Number of Insurance Company. |
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EMERGENCY CONTACT: |
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Person to Notify in Case of an Emergency Enter Full Name, Relationship, Address, Area Code & Telephone Number |
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