Patient Preregistration Form

Please answer the following questions. This will help expedite the registration process. This information is strictly confidential and will only be used to register you or update your information in our Patient Information System. Also have your insurance card available at time of service.

 

Required *

Chief Complaint or Reason for Visit

Summary:

Last time at Henry Mayo for any service including Emergency Room, Outpatient Test or Inpatient

Month: *
Year: *

Patient Information

Last Name : *
First Name : *
Middle Name:
Maiden Name
or AKA : Last
First:
Middle:
Patient Sex: *
Date of Birth: *
  (Format=mm.dd.yyyy)
Social Security #: *
  (Format=xxx-xx-xxxx)   
Race: *
Marital Status: *
Religion:
Patient Address: *
Apt #:
City: *
State: *
Zip Code: *
Home Phone Number: *
Primary Language: *
Employer Name:
Employer Address:
Work Number:
Occupation: *

First Person We Should Contact in an Emergency

Last Name: *
First: *
Middle: *
Relationship to Patient: *
Home Phone #: *
Address:
Apt #:
City:
State:

Second Person We Should Contact in an Emergency

Name Last:
First:
Middle:
Relationship to Patient:
Home Phone #:
Address:
Apt #:
City:
State:

Referring Physician

Doctor's Name : Last *
First: *
Address: *
City: *
State:*
Phone Number: *
Medical Group: *

Guarantor/Responsible Person

Guarantor Name(F/L/M): *
Date of Birth: *
  (Format=mm.dd.yyyy)
Relationship to Patient: *
Social Security Number: *
  (Format=xxx-xx-xxxx)   
Sex: *
Guarantor Address: *
Guarantor Phone Number: *
Guarantor Employer:
Occupation:
Guarantor Retirement Date:
  (Format=mm.dd.yyyy)
Guarantor Employer Address:
City:
State:
Employment Status: *

Insurance Information

Insurance Name: *
Insurance Phone#:
Address: *
City: *
State: *
Policy: *
Group Name: *
Group #: *
Subscriber Name: *
Subscriber Relationship to patient: *
Subscriber Date of Birth: *
  (Format=mm.dd.yyyy)