Doctors Hospital Online Pre-registration

* Required Fields

    
 
* Date of appointment or service:
(For non-scheduled appointments, select the date you plan to come in.)
  • Pre-registration is not available for patients having only lab tests performed.

• If you are a surgery patient, you will be contacted to schedule an appointment for Pre-Surgery Registration to complete labs and paperwork.

• Bring Advance Directive if one has been executed.
Type of Test/Procedure:
Diagnosis:
* Date Symptoms Began:
 (mm/dd/yyyy)
* Ordering Doctor:
Primary Care Physician:
 
 Patient Information
  * First Name: 
  MI: 
 * Last Name:    Suffix:   (ex: jr, sr)
* Address: * County:
* City:
* State:       * Zip: 
Email Address:          Check here if we can correspond with you
via this email address.
* Home Phone: Daytime Phone:
* Social Security: * Birth Date: (mm/dd/yyyy)
* Marital Status: Single       Married       Divorced       Widowed
Religious Preference:
Race: Gender: Male  Female
 
 Employer Information
* Employment Type:
If retired, company
retired from & Date:
Occupation:
Employer: Address:
City:
 State:      Zip: 
Phone:
 
 Responsible Party Information
Check here if Responsible Party Information is same as Patient Information.
  * First Name: 
  MI: 
 * Last Name:    Suffix:   (ex: jr, sr)  
* Address:   * County:
* City:
* State:     * Zip: 
* Home Phone: Alternate/Cell Phone:
* Social Security: * Birth Date: (mm/dd/yyyy)
* Employment Type:
If retired, company
retired from & Date:
Occupation:
Employer: Emp. Address:
Emp. City:
Emp. State:    Emp. Zip: 
Emp. Phone:
 
 Accident Information
          Date of Accident:
 (mm/dd/yyyy)
Accident Type:
 Address:
City:
  State:      Zip: 
Phone:
 
 Emergency Contact Information
* Emergency Contact's Name:
* Emergency Contact's Phone:
* Relation To Patient:
 
 Primary Insurance Information
Check here if you do not have insurance.
* Company Name:
  Address: 
City:
  State:    Zip: 
Phone:  Subscriber SSN:
* Subscribers Name: * Subscribers DOB: (mm/dd/yyyy)
* Relation to Patient:
* Policy Number: Group Number:
 
 Secondary Insurance Information if Applicable
Company Name:
  Address: 
City:
  State:      Zip: 
Phone: Subscriber SSN:
Subscribers Name:   Subscribers DOB: (mm/dd/yyyy)
Relation to Patient:
Policy Number: Group Number:
The names of patients who are registered at Doctors Hospital appear in a daily directory. You have the option of having your name removed from the directory for privacy reasons. Please understand that removing your name means that if anyone calls for you, if flowers are delivered for you, or if someone comes to try to visit you at the hospital we will tell them that you are not here.
Check here if you want to remove your name from Doctors Hospital directory.
Check here if you have an Advance Directive.
Check here if you are an organ donor.
 
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