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Pre Registration

Pre-Registration
Thank you for using our pre-registration form. The information submitted here will allow us to start the registration process prior to your arrival for your test or procedure.
Please complete as much information as possible. Items mark with an Asterisk * are required. If you do not know the answer, put “don’t know” in the box. Please call the patient access department at 912-369-9430 if you have any questions about this form.
* First Name
Enter the patients First Name
* Last Name
* Street Address
  Apt/Lot #
* City
* State GA     SC     FL    
* Zip Code
* County
* Telephone Number
* Date of Birth
MM / DD / YYYY
* Last 4 Digits of Social Security Number
Last 4 Digits of Social Security Number
* Sex FEMALE     MALE    
  Marital Status M Married     S Single     D Divorced     X Separated     W Widow    
* Race
* Religion
  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 not employed.
* 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    
  Fathers Name
  Mothers Name
* Emergency Contact
Who can we contact in the event of an emergency (Name and Address)
* Emergecny Contact Telephone Number
Please provide a working telephone number in case of an emergency
* Insurance Company Name
Please enter the name of your insurance company here (Example: Blue Cross)If you have no insurance, put NONE.
  Inusrance Company Address
Put the mailing address of your insurance company here, if known.
  Insurance Telephone Number
Enter the telephone number of your insurance company here. This number may be on the back of the insurance card.
  Insurance Holder Name
Enter the name that the insurance policy is issued to here.
  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
  Insurance Policy Number
Enter the policy or contract number here.
  Insurance Group Number or Name
Enter the group name or number here
* Expected date of admission
Enter the expected date of this visit or procedure (contact you physician for this information)
* Physician Ordering Test/Procedure or Surgery
Choose the physician that ordred this test/procedure (If your physician is not listed, choose "Other" and enter his/her name in the box below)
  Physician Other (specialists)
If your physician is not listed or you chose "Other" above, please type your physician's name here
* Procedure/Test
Choose the type of procedure or test you will be having during this visit from the options shown