Hospital Pre-Registration Form

Hospital Pre-Registration Form
Please note: This form is for pre-registering for services at Frederick Health Hospital only. Patients with a Frederick Health Medical Group appointment should complete their forms through the Patient Portal.
What Type of Visit Are You Scheduled For?*
Date of Service/Admission*

MonthDayYear
Referring Provider*
Expected Date of Delivery*

MonthDayYear
OB Provider Name*
Date of Last Menstrual Cycle*

MonthDayYear
Primary Care Provider*
YesNo
Patient Information
Full Name*

First NameMiddle NameLast NameSuffix
Preferred Name

First NameLast Name
Pronouns*
Date of Birth*

MonthDayYear
Birth Sex*
Legal Sex*
Marital Status*
Select the option that best describes your current situation
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone Number*
Please enter a valid 10-digit phone number.Format: (000) 000-0000.
Phone Type*
Race*
Ethnicity*
Patient Religion*
Patient Preferred Language
Language*
YesNo
Patient Employment Status
Employment Status
Select your current work arrangement
Retirement Date*

MonthDayYear
Employer Name
Occupation
Veteran Status*
Additional Patient Information
Email Address*
example@example.com
YesNo
YesNoAlready Have an Account
I don't have access to a computerI don't have an email addressI'm not Interested
Do you have any physical handicaps?
Guarantor Information

A guarantor is anyone, typically parents or legal guardians, who takes financial responsibility for the medical expenses of a patient.
YesNo
Guarantor Name*

First NameLast Name
Relationship to Patient*
Guarantor Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Guarantor Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Emergency Contact
Emergency Contact Name*

First NameLast Name
Emergency Contact Relationship to Patient*
Emergency Contact Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Language*
Insurance Information
YesNo
Insurance Company Name*
Primary Member ID/ Policy Number*
Primary Group Number
Subscriber Name*
Subscriber Relationship to Patient*
Subscriber Date of Birth (If Different from Patient)

MonthDayYear
YesNo
Secondary Insurance Company Name*
Secondary Member ID/ Policy Number*
Secondary Group Number
Subscriber Name*
Subscriber Relationship to Patient*
Subscriber Date of Birth (If Different from Patient)

MonthDayYear
YesNo
Date of Accident

MonthDayYear
What type of accident?
YesNo
YesNo
Insurance Company Name*
Primary Member ID/Policy Number*
Primary Group Number
Subscriber Name*
Subscriber Relationship to Patient*
Subscriber Date of Birth (If subscriber is different from patient)*

MonthDayYear
Pharmacy Information
Preferred Pharmacy Name*
Preferred Pharmacy Address*
Preferred Pharmacy Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty:

Hospital Pre-Registration Form

Patient Information

Patient Preferred Language

Patient Employment Status

Additional Patient Information

Guarantor Information

Emergency Contact

Insurance Information

Pharmacy Information