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Patient Pre-Registration

If using online pre-registration, please print, fill out, and bring form listed below with you to your appointment.

AUTHORIZATION TO RELEASE/ACCESS HEALTH INFORMATION FORM

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Patients must Pre-register at least 24 hours in advance of coming to the hospital.

Patient Info

Please bring these 2 items with you to the hospital:
  • Insurance Card
  • Drivers License or Photo ID

 
Month/Day/Year

 
Date that your test or procedure is scheduled.

 
Name of the physician ordering the test or procedure you are pre-registering for.

 
If no physician enter "None"

 

 

 

 

 

 

 

 

 

 
(Example: 555-555-5555)

 
(Cell Phone, Work Phone, etc.)

 

 
Month/Day/Year

 

 
(Example: 555-55-5555)

 Male  Female

 Single  Married  Divorced  Widow  Separated

 Yes  No

 

 Asian  Black  Caucasian  Hispanic  American Indian

 Yes  No

 

 

 

 

 

 


Month/Day/Year

Spouse Info

 

 

 

 

 

Emergency Contact Info

 

 

 

 

 

Payment Info

  Insurance  Cash  Medicaid  Medicare  Credit Card  Debit Card

 


Month/Day/Year

 

Primary Insurance Information


Medicare, Medicaid, Wellmark, Cigna, etc.


If you have Medicare or Medicaid enter "same"


As it appears on your insurance card


Month/Day/Year

 Self  Spouse  Parent  Other


Enter "none" if there is not one.

Secondary Insurance Information


Medicare, Medicaid, Wellmark, Cigna, etc.


If you have Medicare or Medicaid enter "same"


As it appears on your insurance card


Month/Day/Year

 Self  Spouse  Parent  Other


Enter "none" if there is not one.


Please list any drug or latex allergies.