WJMC - West Jefferson Medical Center

WJMC - West Jefferson Medical Center


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.




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