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Woodlawn Hospital

Woodlawn Hospital Patient Pre-Registration Form

To make your registration at Woodlawn Hospital as fast and easy as possible, please complete and submit the following pre-registration form.
Please complete the following information at least 48 hours prior to your scheduled visit.
Remember, a copy of your insurance card, driver's license/ID, and signature is needed in order to finalize your admission.

All information will be kept secure and confidential.

If you have any questions, please call (574) 223-3141. Thank you for choosing Woodlawn Hospital for your healthcare services.
Patient Information
* Reason for Visit
* Admittance Date/Time
mm/dd/yyyy, hh:mm
* Admitting Physician
* Family Physician
* Patient Name
First, Middle Initial, Last
* Street Address or P.O. Box
* City
* County
* State
* Zip Code
Five Digit Zip Code
* Telephone Number
Area Code and 7 Digit Number
  Email
* Date of Birth
mm/dd/yyyy
* Social Security Number
Nine Digit Social Security Number
* Marital Status
* Sex Male     Female    
* Race
  Religion
* Are You Employed? Yes     No    
  Occupation
  Employer's Business Name
  Street Address or P.O. Box
  City
  State
  Zip Code
Five Digit Zip Code
  Employer's Telephone Number
Area Code Plus 7 Digit Number
Spouse's Information
  Spouse's Name
First, Middle Initial, Last
  Spouse's Date of Birth
mm/dd/yyyy
  Spouse's Social Security Number
Nine Digit Social Security Number
  Employer's Business Name
  Street Address or P.O. Box
  City
  State
  Zip Code
Five Digit Zip Code
  Employer's Telephone Number
Area Code and 7 Digit Number
Responsible Party Information
  Name of Responsible Party
First, Last
  Relationship To Patient
  Street Address or P.O. Box
  City
  State
  Zip Code
Five Digit Zip Code
  Telephone Number
Area Code and 7 Digit Number
  Date of Birth
mm/dd/yyyy
  Social Security Number
Nine Digit Social Security Number
  Responsible Party's Occupation
  Employer's Business Name
  Street Address or P.O. Box
  City
  State
  Zip Code
Five Digit Zip Code
  Employer Telephone Number
Area Code Plus 7 Digit Number
Emergency Contact Information
* Person To Notify In Case Of An Emergency
Please Type In Full Name, Relationship, Address, Telephone Number
Primary Insurance Information
Please bring your insurance card to your appointment so we can make a copy to verify coverage and determine if pre-certification is required.
  Policy Holder's Name
  Policy Holder's Date of Birth
mm/dd/yyyy
  Policy Holder's Social Security Number
Nine Digit Social Security Number
  Insurance Company Name
  Street Address or P.O. Box
  City
  State
  Zip Code
Five Digit Zip Code
  Insurance Telephone Number
Area Code and 7 Digit Number
  Policy Number or Identification Number
  Group Number
Secondary Insurance Information
  Policy Holder's Name
  Policy Holder's Date of Birth
mm/dd/yyyy
  Policy Holder's Social Security Number
Nine Digit Social Security Number
  Insurance Company Name
  Street Address or P.O. Box
  City
  State
  Zip Code
Five Digit Zip Code
  Insurance Telephone Number
Area Code and 7 Digit Number
  Policy Number or Identification Number
  Group Number
Additional Information
* Do you have a Living Will or Advance Directive? Yes     No    
* Do you want your admission published in the newspaper?
Inpatient Admissions Only
Yes     No    
* Do you want to receive phone calls? Yes     No