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

Ethnicity*

Religious Preference*

Preferred Language*

Email Address

Employment Status*

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?*

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?