WJMC Surgical Pre-Registration

Surgical Pre-Registration

Identification

Last Name:	First Name:
Middle Init:
Gender:
Marital Status:
Date of Birth:
SSN:
Mailing Address:

City:	State: Zip:
Home Phone:
Work Phone:
Cellular Phone:
Email Address:
Employment Status:
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.