Pre- Registration

Fields marked with * are required.

Procedure Date *

Patient Information

Prefix

First Name *

Middle Name

Last Name *

Suffix

Patient SSN

Place of Birth

Country

State

City *

Sex

Race

Religion

Marital Status

Primary Language

Ethinicity

Patient Date of Birth

Age

Physical Address (911 address)

Address Line 1 *

Address Line 2

City *

State

Zip

Country

County

Contact Information

Primary Phone Type

Alt. Phone #1 Type

Alt. Phone #2 Type

Primary Phone *

Alternative Phone #1

Alternative Phone #2

E-mail address *

Mailing Address

Is your mailing information is same as your Physical Address (911 address)

Address Line 1

Address Line 2

City

State

Zip

Country

County

Additional Patient Information
Primary Care Physician Information

Do You Have a Primary Care Physician:

Last Name

First Name

Physician Clinic Name

Physician Phone Number

Physician Ordering Test

Last Name

First Name

Do You Have a Healthcare Durable Power of Attorney

Do You Have a Living Will

Responsible Party Information

Last Name

First Name

Middle Name

Prefix

Suffix

Responsible Party Date of Birth

Responsible Party SSN

Place of Birth

Country

State

City

Sex

Race

Religion

Marital Status

Primary Language

Ethnicity

Physical Address (911 Address)

Address Line 1

Address Line 2

City

State

Zip

Country

County

Responsible Party Phone Number

Primary Phone

Alt. Phone #1

Alt. Phone #2

E-mail address

Responsible Party Mailing Address

Address Line 1

Address Line 2

City

State

Zip

Country

County

Responsible Party Alternative Address

Address Line 1

Address Line 2

City

State

Zip

Country

County

Patient Employer Information

Employer/ School Name

Employer Status Code

Address Line 1

Address Line 2

City

State

Zip

Country

County

Patient Employer Information (Responsible Party)

Employer/ School Name

Employer Status Code

Address Line 1

Address Line 2

City

State

Zip

Country

County

Patient Emergency Contact (Spouse)

First Name *

Middle Name

Last Name *

Physical Address

Address Line 1

Address Line 2

City

State

Zip

Country

County

Contact Information

Primary Phone Type

Alt. Phone #1 Type

Alt. Phone #2 Type

Primary Phone *

Alternative Phone #1

Alternative Phone #2

Nearest Relative other than spouse

Relation

First Name *

Middle Name

Last Name *

Physical Address

Address Line 1 *

Address Line 2

City *

State

Zip

Country

County

Contact Information

Primary Phone Type

Alt. Phone #1 Type

Alt. Phone #2 Type

Primary Phone *

Alternative Phone #1

Alternative Phone #2

Emergency Contact

Relation

First Name *

Middle Name

Last Name *

Physical Address(Emergency Contact)

Address Line 1 *

Address Line 2

City *

State

Zip

Country

County

Contact Information

Primary Phone Type

Alt. Phone #1 Type

Alt. Phone #2 Type

Primary Phone

Alternative Phone #1

Alternative Phone #2

Patient Father Name

Last Name

First Name

Date of Birth

Patient Mothers Name

Last Name

First Name

Date of Birth

Miscellaneous Information

Chief Complaint/Diagnosis

Testing Department:

Are You A Veteran

Do You Have Medicare

IF Yes to Medicare, please complete the following

What is the reason for your medicare entitlement:

Are You Receiving Black Lung Benefits

Have these services been authorized and agreed to be paid for by the Department of Veterans affairs? If the answer is yes display message: Be sure to bring a copy of

your authorization letter with you on the date of service.

Are these services to be paid as part of a government sponsored research project:

If Yes, list program name here

Are These Services being ordered as a result of an accident

Have You Smoked in the last 12 months

Insurance Information

Do you have Insurance?

Company Name

Subscriber's Last Name

Subscriber's First Name

Subscriber's Middle Name

Subscriber's SSN

Subscriber's DOB

Policy Number

Group Number

Policy Phone Number

Phone Number

Alt Phone1

Alt Phone2

Insurance Information 2

Do you have Insurance?

Company Name

Subscriber's Last Name

Subscriber's First Name

Subscriber's Middle Name

Subscriber's SSN

Subscriber's DOB

Policy Number

Group Number

Policy Phone Number

Phone Number

Alt Phone2

Insurance Information 3

Do you have Insurance?

Company Name

Subscriber's Last Name

Subscriber's First Name

Subscriber's Middle Name

Subscriber's SSN

Subscriber's DOB

Policy Number

Group Number

Policy Phone Number

Phone Number

Alt Phone2

Security question
6 + 4 =

Southeastern Health

Pre- Registration

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