Surgery Center Pre-Registration

"*" indicates required fields

Patient Information

Patient Full Name

First*

First

Middle

Last*

Last

Patient Maiden Name

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

Place of Birth

Marital Status

Race

Primary Language

Sex/Gender

Male

Female

Does the patient smoke?

Yes

Would you like your visit to the Surgery Center 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.

Emergency Contact

Contact's Full Name*

Relationship to Patient*

Contact's Address*

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

Contact's Primary Phone*

Contact's Secondary Phone

Admission Information

Admitting Physician's Name*

Treating Physician's Name*

Primary Care Physician's Name*

Expected Admission Date*

Type of Procedure/Treatment/Test*

Name of Obstetrician

Due Date

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

Primary Insurance Provider*

Insurance Company Phone Number

Insurance Co. Pre-certification Phone Number

Policy Holder/Beneficiary Name as on Insurance Card*

Policy Holder's Social Security Number*

Policy Holder's Birthdate

Policy/Contract Number or Member ID*

Policy Group Name*

Policy Effective Date

Address

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

Secondary Insurance Provider

Insurance Company Phone Number

Secondary Insurance Policy Holder/Beneficiary

Policy Holder's Social Security Number

Secondary Insurance Policy/Contract Number or Member ID

Secondary Insurance Group Name

Secondary Insurance Effective Date

Address

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