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Pre-Registration Form

Hamilton Health Care System logo

PRE-REGISTRATION QUESTIONNAIRE

  • Previous visit?
  • MM slash DD slash YYYY

  • Personal Information

  • MM slash DD slash YYYY
  • Drop files here or
    Accepted file types: jpg, gif, png, pdf, bmp, jpeg, Max. file size: 50 MB, Max. files: 3.
      If available, please upload a copy of your photo ID.

    • Do you have a living will?
    • Do you have power of attorney for health care?
      If yes, please bring a copy to the hospital with you.

    • Insurance Information - Medicare/Medicaid

    • Group Insurance Company #1

    • Drop files here or
      Accepted file types: jpg, gif, png, pdf, bmp, jpeg, Max. file size: 50 MB, Max. files: 3.
        If available, please upload a copy of your insurance card.

      • Group Insurance Company #2

      • TRICARE

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