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Find A Doctor
Search Providers
Online Scheduling
Our Locations
Emergency Room
Providence Health
Providence Health Northeast
Providence Health Fairfield
For Patients & Visitors
About Us
Bill Pay
Gift Shop
Pastoral Care
Patient Portal
Pre-Registration
Patient Follow Up Survey
Non-Discrimination Notice
Patient Rights and Responsibilities
Understanding Your Healthcare Costs
Third Party Applications
Prisma Health Announcement
Records Request
Our Services
Find A Doctor
Cardiology
Cardiopulmonary Rehab & Fitness
Emergency Department
Home Health Services
Imaging
Orthopedics
Outpatient Rehabilitation
Palliative Care
Pulmonary care
Sleep Disorders Center
Surgery
Urology
Vascular Health
Vein Center
Wound Care
Classes & Events
For Healthcare Professionals
Career Opportunities
Nurses Station
Physician Opportunities
Clinical Education
Referral Forms
LifeTalent Learning Center
Nurse Residency Program
Respiratory Therapist Residency Program
Community Resources
Project SEARCH
Social Media
Sponsorship Request
Volunteer
Home
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For Patients & Visitors
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Pre-Registration
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Appointment Pre-Registration
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Appointment Pre-Registration
Pre-Registration helps to ensure all necessary information has been obtained prior to your arrival. This helps to decrease your wait time and makes your visit as stress free as possible.
Patient's Name in full
Date of Birth
*
Social Security Number
*
Mailing Street Address
*
Home Phone Number
*
Cell Phone or Alternate Phone Number
*
Marital Status
Marital Status
Divorced
Life Partner
Married
New Value
Separated
Single
Widowed
Ethnicity
*
Ethnicity
African American
American Indian
Asian
Caucasian
Decline
Latino
Other
Pacific Islander
Prefer not to answer
Religious Preference
*
Religious Preference
AME
Anglican
Apostolic
Assembly of God
Atheist
Baptist
Buddhist
Catholic
Greek Orthodox
Hindu
Holiness
Independent
Jehovah Witness
Jewish
Lutheran
Mennonite
Methodist
Mormon
Muslim/Islamic
Non-Denominational
None
Other
Prefer not to answer
Presbyterian
Protestant
Seventh Day Adventist
Western Orthodox
Preferred Language
*
Preferred Language
Arabic
Chinese
English
French
German
Greek
Hebrew
Hindi
Italian
Japanese
Korean
Other
Russian
Sign
Spanish
Togalos
Vietnamese
Email Address
Employment Status
*
Employment Status
Active Duty Military
Disabled
Full-time
Not Employed
Part-time
Retired
Self-Employed
Employer Name and Address
*
Employer Phone
*
Next of Kin Name and Address
*
Next of Kin Phone
*
Relationship of Next of Kin to Patient
*
Additional In Case of Emergency Contact
Additional In Case of Emergency Phone
Relationship of Additional In Case of Emergency Contact to Patient
Do you wish to Opt-Out of the online Patient Portal/SCHIEx?
*
I'd like more information
No
Yes
Do you consent to visits and/or post-discharge calls by Mended Hearts volunteers?
*
No
Yes
Do you consent to visits by Pet Therapy volunteers?
*
No
Yes
Primary Insurance Provider - Name and Address
*
Primary Insurance Provider - Phone Number
*
Primary Insurance - Policy Number
*
Primary Insurance - Group Name and Group Number
*
Primary Insurance - Subscriber Name and Address
*
Primary Insurance - Subscriber Phone Number
*
Primary Insurance - Subscriber Birthdate
*
Primary Insurance - Subscriber SSN
Secondary Insurance Provider - Name and Address
*
Secondary Insurance Provider - Phone Number
Secondary Insurance - Policy Number
Secondary Insurance - Group Name and Group Number
*
Secondary Insurance - Subscriber Name and Address
Secondary Insurance - Subscriber Phone Number
Secondary Insurance - Subscriber Birthdate
Secondary Insurance - Subscriber SSN
Tertiary Insurance Provider - Name and Address
*
Tertiary Insurance Provider - Phone Number
Tertiary Insurance - Policy Number
Tertiary Insurance - Group Name and Group Number
Tertiary Insurance - Subscriber Name and Address
Tertiary Insurance - Subscriber Phone Number
Tertiary Insurance - Subscriber Birthdate
Tertiary Insurance - Subscriber SSN
Preferred Pharmacy - Name and Address
*
Preferred Pharmacy - Phone Number
*
The Guarantor / Responsible Party is:
*
different from the patient (i.e. if the patient is a minor)
the same as the patient
Guarantor / Responsible Party Information, if different from the patient:
At which Providence Health location are you having your procedure?
*
Providence Health - Forest Dr.
Providence Health Northeast - Gateway Corp. Blvd
Other
Who is the physician who normally sees you for this condition?
*
Which physician is doing your scheduled procedure?
*
Who is your Family Physician or Primary Care Doctor?
*
What is the scheduled date for your procedure?
*
Which type of service are you having?
*
Cardiac
General Surgery
GI
Imaging
Orthopedic
Other
Do you have a living will?
*
No
No, but I am interested in information on how to get one.
Yes
Based on religious, cultural or ethnic concerns, do you have any objection to receiving blood/blood products in the event of an emergency?
*
No
Yes
If you have someone designated as Health Care Power of Attorney, please write his/her name here.
Any comments you wish to add?
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Appointment Pre-Registration
Pre-Admission Testing
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Patient Rights and Responsibilities
Understanding Your Healthcare Costs
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Prisma Health Announcement
Records Request