• Stroke/Aneurysm Screenings
  • Children's Peace Center
  • Send a Patient Greeting Card
  • Sleep Disorder Center
  • Minimally Invasive Surgery
  • After Hours Care
  • Friends of Frazier


Patient Pre-Registration

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* Denotes a required field.

Jewish Hospital & St. Mary's HealthCare offers on-line pre-registration for all patients scheduled for outpatient surgery, endoscopy, diagnostic and invasive services at the following facilities:

  • Jewish Hospital Outpatient Care Center
  • Jewish Hospital Medical Center East
  • Jewish Hospital Medical Center Northeast
  • Jewish Hospital Medical Center South
  • Jewish Hospital Medical Center Southwest
  • Jewish Hospital Shelbyville
  • Sts. Mary & Elizabeth Hospital

Pre-Registration hours are 9:00 a.m. to 9:00 p.m. Monday - Friday. Online pre-registration must be submitted 24 hours in advance of procedure.

Please complete and submit the form below to pre-register for your visit. If you need additional assistance, please call Jewish Hospital Outpatient Registration at .

Many insurance companies require either a pre-certification number or a physician referral. Please check with your insurance company to ensure that appropriate authorization has been obtained for your procedure.

Patient Information

Where is your appointment?

* Name:
Maiden Name:
* Address:
* City:
* State:
*Zip: ex. #####
Home Phone: ex. xxx-xxx-xxxx
* Email:
May we respond to you via email?
SSN #:
Date of Birth: ex. MM/DD/YYYY
Are you allergic to latex? (or any natural rubber products i.e. physician gloves)

Marital Status:

Spouse's Name:
* Primary (Family) Doctor:
Do you have a living will or health care surrogate?
Have you ever had an organ transplant?
Have you ever been a patient at Jewish Hospital?
Patients Employer:
Employment Status:
Work Phone Number: ex. xxx-xxx-xxxx
Zip Code: ex. #####
Date of arrival:
Physician ordering test?
Referring Physician (who sent you to the doctor ordering the test)?
What are you coming for?

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© 2013 KentuckyOne Health
200 Abraham Flexner Way•Louisville, KY•40202

Last Updated: 7/16/2014