Physicians       Employees
Search  
Print    Email
Decrease (-) Restore Default Increase (+)
Patient Pre-registration

Please be sure and bring any orders and/or papers your doctor's office has given you. The day of your actual visit, be prepared to pay any co-pays, deductibles or other amounts due, pertaining to this visit. This information sheet should be received no less than 3 days prior to your actual visit date.

* Asterisk indicates a required field.

First Name *  
Last Name *  
Middle Name
Address  
Phone # *  
Mobile #
Email Address *  
Date of Birth *  
Social Security # *  
Sex *  
Race
Religion
Marital Status
Language
Ethnicity  
Procedure/Visit Date
Admitting Physician
Referring Physician

If different than patient, answer guarantor information below:
Guarantor Name
Guarantor DOB
Guarantor SSN
Guarantor Address  

Employer Information
Employer Name
Employer Phone
Employer Address

Spouse's Information ( If applicable )
Spouse's Name

Emergency Contact Information ( Should be someone outside of the home )
Name
Relationship
Phone #

Insurance Information
Primary Ins Co
ID#
Group#
Subscriber
Subscriber DOB
Subscriber SSN
Subscriber's Employer
Secondary Ins Co
ID#
Group#
Subscriber
Subscriber DOB
Subscriber SSN
Subscriber's Employer
Is this visit due to an accident? If yes type ( work, auto or other )
Patient's Retirement Date
Spouse's Retirement Date
Surgery/Procedure/Visit Reason
Diagnosis
Do you currently have an advance directive or living will?
For your security protection, please type the two words in the box. * 

If the challenge words are too difficult to read, click here to refresh.

Please be sure and bring any orders and/or papers your doctor's office has given you. The day of your actual visit, be prepared to pay any co-pays, deductibles or other amounts due, pertaining to this visit. This information sheet should be received no less than 3 days prior to your actual visit date.

West Tennessee Healthcare  |  620 Skyline Drive, Jackson, TN 38301  |  731-541-5000
Copyright 2012 West Tennessee Healthcare  |  
Privacy Notices