Pre-Registration

Pre-Registration Form
Patient Information
First Name
Middle Initial
Last Name
Have you ever been registered/or seen with a different name?
Give Name
Email Address
(Please enter none if you don't have an email address)
Check here if you would like to receive health and wellness updates from Monterey Park Hospital.
Patient Address
City
State
Zip Code
Phone Number
Cell Phone
Sex
Date of Birth
Place of Birth
Social Security (not required)
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Marital Status
Race
Ethnicity
Preferred Language
Other
Religious Affiliation
Employment Status
Occupation
Employer Phone #
Employer Name
Employer Address
Admission Information
Are You a Returning Patient?
Primary Care Physician / Family Doctor
Chief Complaint
Expected date of conception (for labor and delivery)
Expected date of procedure (for non-maternity)
Expected Admission Time
Please list your Current Medication Information
Type of Procedure
Spouse or Guarantor Information
Spouse First Name
Spouse Last Name
Relationship
Spouse or Guarantors Social Security #
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Spouse or Guarantor’s Address

Same as Patient Address

City
State
Zip Code
Telephone

Same as Patient Phone

Spouse or Guarantor's Employment Status
Method of Contact
Best Way to Contact You
Best Time to Contact You
If there is a financial liability (i.e. co-payment, deductible, etc) what is your preferred method of payment?
Emergency Contact Information
Contact Person First Name
(Please enter none if you don't have an emergency contact)
Contact Person Last Name
Relationship to Contact
Address
Phone Number
MEDICARE Patients
Medicare Number
Patient Retirement Date
Spouse Retirement Date
Spouse Date Of Birth
Accident / Injury
Date of Injury
Time of Injury
Injury Locations
Work Auto Other
Claim #
Very Brief Accident Description
Adjuster's Name
Adjuster's Phone Number
Primary Insurance
Subscriber Name
(Please enter self-pay if you don't have primary insurance)
Subscriber Social Security # (not required)
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Subscriber Date of Birth
Relationship to Patient
Name of Insurance
Insurance Phone #
Billing Address
Policy / Member #
Group #
Employer
Employer Phone #
Employer's Address
Secondary Insurance
Subscriber Name
Subscriber Social Security #
--
Subscriber Date of Birth
Relationship to Patient
Name of Insurance
Insurance Phone #
Billing Address
Policy / Member #
Group #
Employer
Employer Phone #
Employer's Address
Advanced Directive
Advance Directive?
If yes please bring to facility on date of service