First Admit

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Patient Information

First Name*

Middle Initial

Last Name*

Social Security Number*

Date of Birth*

Can enter manually.

Sex at Birth*

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Gender*

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Marital Status*

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Race

If Other Race, please specify

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Ethnicity

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Home Address*

City*

State*

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Zip Code*

Primary Phone Number*

(XXX-XXX-XXXX)

Phone

Your Email Address*

Your email address is required, so that we may send you confirmation that registration information has been received.

Is the Patient a Citizen or an Alien lawfully present in the US?*

This question will NOT impact patient care.

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Is the Patient an Alien NOT lawfully present in the US?*

This question will NOT impact patient care.

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Patient Employment Information

If employed, please fill all information in this section.

Employment Status*

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Date Retired*

Can enter manually.

Company Name*

Work Phone

(XXX-XXX-XXXX)

Phone

Emergency Contact Information

Name*

Relationship

Primary Phone*

(XXX-XXX-XXXX)

Phone

Secondary Phone

(XXX-XXX-XXXX)

Phone

Add Secondary Emergency Contact?

Name*

Relationship

Primary Phone*

(XXX-XXX-XXXX)

Phone

Secondary Phone

(XXX-XXX-XXXX)

Phone

Primary Insurance Information

If you do not have all information available to you while completing this portion of the Pre-Registration process, please complete what you can.

Are You Insured?*

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If Medicare or Medicaid, then only enter Insurance Policy Number below:

Name of Insurance Company

Address

City

State

Select or enter value

Zip Code

Phone Number

(XXX-XXX-XXXX)

Phone

Insurance Policy Number*

Group Number

Is the patient the policy holder?

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Name of policy holder

Patient Relationship to Policy Holder

Select or enter value

Policy Holder's D.O.B

Can enter manually.

Policy Holder's SSN

Secondary Insurance Information

If you do not have all information available to you while completing this portion of the Pre-Registration process, please complete what you can.

Add Secondary Insurance?

If Medicare or Medicaid, then only enter Insurance Policy Number below:

Name of Insurance Company

Address

City

State

Select or enter value

Zip Code

Phone Number

(XXX-XXX-XXXX)

Phone

Insurance Policy Number*

Group Number

Is the patient the policy holder?

Select

Name of policy holder

Patient Relationship to Policy Holder

Select or enter value

Policy Holder's D.O.B

Can enter manually.

Policy Holder's SSN

Tertiary Insurance Information

If you do not have all information available to you while completing this portion of the Pre-Registration process, please complete what you can.

Add Tertiary Insurance?

If Medicare or Medicaid, then only enter Insurance Policy Number below:

Name of Insurance Company

Address

City

State

Zip Code

Phone Number

(XXX-XXX-XXXX)

Phone

Insurance Policy Number*

Group Number

Is the patient the policy holder?

Select or enter value

Name of policy holder

Patient Relationship to Policy Holder

Select or enter value

Policy Holder's D.O.B

Can enter manually.

Policy Holder's SSN

Visit Reason

What is the reason for this visit?*

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Newborn Delivery: Admission Information

Expected Due Date*

If yes, please provide approximate due date. (Can enter manually.)

Last Menstrual Cycle*

OB Physician

Primary Care Physician

Delivery Type

Select

Scheduled Procedure

Appointment Date

Reason for Visit

Date Symptoms Began

Physician Ordering Tests/Procedures*

Primary Care Physician

All patient payment amounts (co-pay, co-insurance, deductibles) are requested at the time of service. We accept cash, personal checks, major credit cards, and bank drafts.

Self-pay patients who either have no insurance or are not covered for the purpose of the visit, and who are unable to pay the entire amount at the time of service, will be asked to pay a deposit equaling 50% of estimated charges at time of service.

Financial arrangements and/or screening for medical assistance programs such as Medicaid can be made by contacting (325) 670-4160

We welcome any comments or suggestions you may have.

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