Hospital Visit Information
* Fields marked in red are required.
Reason for Visit:  
Reason Description:  
Family Physician First Name:
Family Physician Last Name:
Ordering Physician First Name:
Ordering Physician Last Name:
Scheduled Date:
(Scheduled Date must be at least 3 business days in the future)
Patient Information

First Name:
Middle Initial
Last Name:
Date of Birth:
Social Security Number:
Sex:

Marital Status:

Race:
Ethnicity:
Religion
Primary Language:
Address 1:
Address 2:
City:
State:
Zip:
County:
Home Phone:
Mobile Phone:
Work Phone: Ext:
E-Mail Address:

Patient Employment Information

Is the patient currently employed?
Employer Name:
Address 1:
Address 2:
City:
State:
Zip:


Next of Kin Information

First Name:
Middle Initial
Last Name:

Address 1:
Address 2:
City:
State:
Zip:
County:
Home Phone:
Mobile Phone:
Work Phone: Ext:
Relationship to Patient:

Notify In Case of Emergency Information

First Name:
Middle Initial
Last Name:

Address 1:
Address 2:
City:
State:
Zip:
County:
Home Phone:
Mobile Phone:
Work Phone: Ext:
Relationship to Patient:

Insurance Information

Does the Patient currently have insurance?

Insurance Company Name:
Policy Number
Group Number:
Customer Service Phone Number:

Policy Holder Information
First Name:
Middle Initial:
Last Name:
SS #
Date of Birth:
Employer Name:
Address 1:
Address 2:
City:
State:
Zip:
Relationship to Patient:


Does the Patient have additional insurance?

Insurance Company Name:
Policy Number
Group Number:
Customer Service Phone Number:

Policy Holder Information
First Name:
Middle Initial:
Last Name:
SS #
Date of Birth:
Employer Name:
Address 1:
Address 2:
City:
State:
Zip:
Relationship to Patient:


Does the Patient have a third insurance?

Insurance Company Name:
Policy Number
Group Number:
Customer Service Phone Number:

Policy Holder Information
First Name:
Middle Initial:
Last Name:
SS #
Date of Birth:
Employer Name:
Address 1:
Address 2:
City:
State:
Zip:
Relationship to Patient:

Responsible Party Information

Is the Responsible Party the same as the patient?
First Name:
Middle Initial
Last Name:

Address 1:
Address 2:
City:
State:
Zip:
County:
Home Phone:
Mobile Phone:
Work Phone: Ext:
Relationship to Patient:
Is the Responsible Party currently employed?
Employer Name:
Address 1:
Address 2:
City:
State:
Zip:


Is there another Responsible Party?
First Name:
Middle Initial
Last Name:

Address 1:
Address 2:
City:
State:
Zip:
County:
Home Phone:
Mobile Phone:
Work Phone: Ext:
Relationship to Patient:
Is the Responsible Party currently employed?
Employer Name:
Address 1:
Address 2:
City:
State:
Zip:

Additional Comments:
notification preferences

For confirmation of this pre-registration service, please let us know how you would like us to notify you:

  
     

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Doctors Hospital at Renaissance proudly meets the federal definition of a physician-owned hospital (42 CFR § 489.3).