Patient Pre-Registration

"*" indicates required fields

Information About Upcoming Visit to Cullman Regional

Procedure/Test Date*

What type of procedure/test are you having?*

Primary Physician*

Referring Physician (if applicable)

Patient Information

Patient Full Name

First*

First

Middle

Last*

Last

Address*

Mailing Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Secondary Address

Mailing Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone*

Secondary Phone

Patient Email

Social Security Number*

Date of Birth

Marital Status

Race

Primary Language

Sex/Gender

Male

Female

Does the patient smoke?

Yes

Would you like your visit to Cullman Regional to be confidential?

Yes

Do you have an advance directive?

Yes

An advance directive is used to tell your doctor and family what kind of medical care you want if you are unable to speak or make decisions for yourself. If you do not have an advance directive and are unable to make decisions about your health care, members of your family will have to decide on your care for you.

Is the reason for visit due to an accident or injury?

Yes

If yes, is the accident or injury work related?

Yes

Not applicable

If accident/injury is work related, what is the date and time it occurred?

How did the accident occur?

If NOT accident related, what is the date/time symptoms started?

Emergency Contact

Contact's Full Name*

Relationship to Patient*

Contact's Primary Phone*

Contact's Secondary Phone

Employment Information

Employment Status*

Employed

Unemployed

Retired

Disabled

Employer's Name*

Employer's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Position/Title*

Type of Position*

Full Time

Part Time

PRN

N/A

Retirement Date

Responsible Party Information

Is the patient listed above the responsible party?*

Yes

Please fill out the responsible party information:

Full Name*

Relationship to Patient*

Date of Birth

Social Security Number*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone*

Secondary Phone

Employer

Employer's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer's Phone Number*

Position/Title

Type of Position*

Full Time

Part Time

PRN

N/A

Payment Information

Is this visit/procedure related to a Worker's Compensation claim?*

Yes

Is this visit/procedure related to an Auto Liability claim?*

Yes

How do you plan to pay?

Insurance

Cash

Medicare

Medicaid

Insurance Information

Insurance Provider*

Policy Holder/Beneficiary*

Policy/Contract Number or Member ID*

Group Number*

Policy Effective Date

Secondary Insurance Provider

Secondary Insurance Policy Holder/Beneficiary

Secondary Insurance Policy/Contract Number or Member ID

Secondary Insurance Group Number

Secondary Insurance Effective Date