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Online Pre-Registration

Thank you for choosing St. Anthony North Hospital for your health care needs. Please remember that to effectively process your pre-registration we must receive it at least 48 hours prior to your scheduled procedure. If you have less than 48 hrs before the time of your procedure, you will need to call the hospital to complete the pre-registration process.

A note about our data security and your privacy: The security of your personal and health information is paramount to us at Centura Health and our hospital facilities. Our data encryption ensures that the information you submit here is protected and secure. The pre-registration form you complete is housed on a secure server assuring that your information is protected and that our process meets HIPAA  (Health Insurance Portability & Accountability Act of 1996) guidelines. Your information will be used solely for the purpose of pre-registration and your medical record. Centura Health and your local hospital do not share information with any outside organizations other than that shared with your insurance company to process your claim. Our secure server protects your personal and health information.



* Indicates required information
------ Important information about your scheduled procedure ------ 
Procedure/Test: * 
Date & Time of procedure: * 
Authorization Number:  
------ Patient Information ------ 
First Name: * 
Middle Name: * 
Last Name: * 
Maiden Name: 
Date of Birth: *  (mm/dd/yyyy)
Place of Birth: * 
Social Security Number: 
Sex: * 

Race: 
Marital Status: 
Religious Preference: 
Address of record 1: * 
Address of record 2: 
City: * 
County: 
State: * 
Zip: * 
Phone Number: * 
May we contact you at home? * 

Alternate Phone: 
Email Address: * 
Primary Care Physician (first & last name): * 
Referring Physician (first & last name): 
Due Date (OB):  (mm/dd/yyyy)
C-Section Date:  (mm/dd/yyyy)
Admitting Physician (first & last name): * 
Diagnosis: 
Have you had a persistant cough for more than 3 weeks? * 

------ Employment Information ------ 
Employment Status: 
Employed By: * 
Employer Address 1: 
Employer Address 2: 
Employer City: 
Employer State: 
Employer Zip: 
Employer Phone: 
------ Emergency Contact Information ------ 
Emergency Contact Name: * 
Emergency Contact Phone: * 
Relationship to Patient: 
2nd Emerg. Contact Name: 
2nd Emerg. Contact Phone:  
Relationship to Patient: 
------ If visit is related to Accident or Injury - Please complete the following ------ 
Accident/Injury Date:  (mm/dd/yyyy)
Accident/Injury Type: 
Accident/Injury Time: 
Accident/Injury Place: 
------ Responsible Party (If patient is under 18 years of age) ------ 
First Name: 
Last Name:  
Date of Birth:  (mm/dd/yyyy)
Social Security Number: 
Relationship to Patient: 
Address: 
City: 
State: 
Zip: 
Phone (with area code): 
Employment status: 
Employed by: 
Employer Address 1: 
Employer Address 2: 
Employer City: 
Employer State: 
Employer Zip: 
Employer Phone: 
------ Insurance Information ------ 
Primary Insurance Name: 
Primary Insurance Type: 
Policy Holder's Name: 
Policy Holder's DOB: 
Policy Holder's SSN: 
Insurance ID#: 
Group Name: 
Group Number: 
Insurance Address: 
Insurance City: 
Insurance State: 
Insurance Zip: 
Insurance Phone: 
Primary Insured Employer: 
Employer Address 1: 
Employer Address 2: 
Employer City: 
Employer State: 
Employer Zip: 
Employer Phone: 
------ Secondary Insurance (where applicable) ------ 
Secondary Insurance Info: 
------ If Military Insurance ------ 
Branch of Service: 
Status: 
Pay Grade: 
Retirement Date: 
------ Can we keep you informed? ------ 
Would you like to receive information on community screenings, e-newsletters, information on preventive services and other health-related information from our hospital via email? * 

Authentication * 

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Please remember that to effectively process your pre-registration we must receive it at least 48 hours prior to your scheduled procedure. If you have less than 48 hrs before the time of your procedure, you will need to call the hospital to complete the pre-registration process.

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