Pre-Registration for Outpatient Surgery, Imaging procedure

You can get the process started now for your upcoming outpatient surgery or imaging appointment by filling out the form below.

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First Name *Middle Initial *Last Name *Date of Birth *Email address *Phone Number *Street address *Street Address 2City *State *

Zip Code *Marital Status

Ethnicity *

Latino/Hispanic

Non-Latino/Hispanic

Race

ReligionSocial Security Number *Name of Primary Care PhysicianDate of Appointment *Is this visit due to an accident? *

Yes

No

Employer

EmployerAddressCityState

Zip CodePhone NumberFax Number

Next of Kin

Name of Next of Kin *Relation to patientAddressCityState

Zip CodePhone Number *

Person to Notify

Name *Relation to PatientAddress *City *State *

Zip Code *Phone Number *Work Phone

Insurance

Insurance Company Name *Insurance Phone *Insurance ID *Group Number *Claims Address *Insurance Subscriber Name *Patient Relation to Subscriber *

Subscriber Date of Birth *Subscriber Social Security Number *Subscriber Address *Guarantor (18+ is self) (-18 is guardian) *Patient relation to GuarantorGuarantor Name *Guarantor Address *Guarantor Phone *

Secondary Insurance Company

Secondary Insurance CompanyInsurance PhoneInsurance IDGroup NumberClaims AddressInsurance Subscriber NamePatient Relation to SubscriberSubscriber Date of BirthSubscriber Social Security NumberGuarantor (18+ is self) (-18 is guardian)Patient relation to GuarantorGuarantor NameGuarantor AddressGuarantor Phone Number

HIPAA Questions

If you become inpatient during your visit, would you like a minister of your faith to visit you while you are in the hospital? *

Yes

No

Would you like your name and location released to those who request it while you are at the hospital? *

Yes

No

St. Joseph's Hospital Campus

Candler Hospital Campus

Pooler Campus

Pre-Registration for Outpatient Surgery and Imaging