Patient Pre-Registration

You are on step 1 of 7

* 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?	Jewish Hospital 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
* Name:	FIRST   MI   LAST
Maiden Name:
* Address:
* City:
* State:
*Zip:	ex. #####
Home Phone:	ex. xxx-xxx-xxxx
* Email:
May we respond to you via email?	Yes No
SSN #:
Date of Birth:	ex. MM/DD/YYYY
Religion:
Are you allergic to latex? (or any natural rubber products i.e. physician gloves)	Yes No
Race:	Caucasian African-American Hispanic Other
Sex:	Male Female
Marital Status:	Single Married Widowed Divorced
Spouse's Name:
* Primary (Family) Doctor:
Do you have a living will or health care surrogate?	Yes No
Have you ever had an organ transplant?	Yes No
Have you ever been a patient at Jewish Hospital?	Yes No
Patients Employer:
Employment Status:	Full Time Part Time
Address:
Work Phone Number:	ex. xxx-xxx-xxxx
City:
State:
Zip Code:	ex. #####
Position:
Date of arrival:
Physician ordering test?
Referring Physician (who sent you to the doctor ordering the test)?
What are you coming for?	Surgery Testing MRI/PET

     Next Step