Surgical Pre-Registration Identification   Last Name:   First Name:   Middle Init: Gender: -- Select -- Male Female   Marital Status: -- Select -- Single Married Separated Divorced Unknown   Date of Birth: SSN: Mailing Address:   City:     State:     Zip Code:   Home Phone: Work Phone: Cellular Phone: Email Address: Employment Status: -- Select -- Full Time Part Time Retired Unemployed   Employer Name: Employer Phone Number:     Guarantor Information   Guarantor Name: Date of Birth: SSN:     Emergency Contact Information   Emergency Contact Name: Relationship to Patient: Phone Number:     Medical Information   Diagnosis: Diagnosis Code: Admitting Physician: Primary Care Physician: Date of Surgery: Procedure Name:     Insurance Information   Insurance Company: Policy #: Group Name:     Group #: Insurance Phone Number: Subscriber Name:     Subscriber SS#: Subscriber Date of Birth:     Additional Notes or Comments

REMINDER Please call 504-349-2437, Monday-Friday 8:00am-4:30pm to schedule your Pre-Operative appointment to include Anesthesia consultation, Pre-Op Nurse Consultation, and any lab, EKG or chest x-ray ordered by your Physician. Please be aware that this process may take between 1.5-2.0 hours to complete, so please schedule your appointment accordingly. Thank you for choosing West Jefferson Medical Center for your healthcare needs.