PRE-REGISTRATION QUESTIONNAIRE Previous visit? Yes No Appointment Date: - must be mm/dd/yyyy format MM slash DD slash YYYY Personal InformationName * Required First Middle Last Birth Date - must be mm/dd/yyyy format * Required MM slash DD slash YYYY Race: Address * Required Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Photo ID Drop files here or Select files 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. Email Address Phone (home)Phone (cell)Phone (work)Employer: Occupation Employer's Phone: Primary Care Physician Ethnicity? * Required Hispanic Non-Hispanic Unknown Status * Required Single Married Widowed Divorced EMERGENCY CONTACT * Required First Last EMERGENCY CONTACT PHONEDo you have a living will? Yes No Do you have power of attorney for health care? Yes No If yes, please bring a copy to the hospital with you.Insurance Information - Medicare/MedicaidMedicare Number: Name as Appears on Medicare Card: Medicaid Number: Name as Appears on Medicaid Card: Group Insurance Company #1Insurance Card Drop files here or Select files 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 #1 Policy Holder: (PH) Guarantor: PH's Date of Birth: Policy Holder Social Security Number: Employer's Name: Group Number: Policy Number/ID Number: Group Insurance Company #2Group Insurance Company #2: Policy Holder: Policy Holder's Date of Birth: Policy Holder Social Security Number: Employer's Name: Group Number: Policy Number/ID Number: TRICARE Yes No If No Insurance, Check: None