|
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 |
|
|