Your browser does not support JavaScript!
This form cannot automatically check that you have submitted all of the required fields without JavaScript.
Please be sure to submit all required fields (marked with stars).

Woodlawn Hospital

Woodlawn Internal & Critical Care Medicine Child Patient Pre-Registration Application

To make your registration as fast and easy as possible, please complete and submit the following pre-registration form.
Please complete the following information at least 48 hours prior to your scheduled visit.
Remember, a copy of your insurance card, driver's license/ID, and signature is needed in order to finalize your office visit.

All information will be kept secure and confidential.
  Today's Date
Patient Information
  Patient Full Name
First Name, Middle Initial, Last Name
  Date of Birth
  Sex Male     Female    
  Age
  Last 4 Digits of Social Security Number
Last 4 Digits of Social Security Number
  Language English     Spanish     Other    
  Race Asian     Black     Indian/Native American     Pacific/Hawaiian     White    
  Hispanic? Yes     No    
  If over age 12: Smoker? Current Every Day     Current Some a Day     Former     Never    
  School Name
If patient is a student, please list name of school.
  School Status Full Time     Part Time    
Father's Information
  Name
  Address
  City
  State
  Zip Code
  Date of Birth
  Age
  Last 4 Digits of Social Security Number
Last 4 Digits of Social Security Number
  Employer
  Employer Address
  Home Phone
  Cell Phone
  Work Phone
Mother's Information
  Name
  Address
  City
  State
  Zip Code
  Date of Birth
  Age
  Last 4 Digits of Social Security Number
Last 4 Digits of Social Security Number
  Employer
  Employer Address
  Home Phone
  Cell Phone
  Work Phone
Referring Physician
  Physician's Name
Primary Care Physician (if different from Referring Physician)
  Physician's Name
General Information
  Emergency Contact Name
  Date of Birth
  Relationship to Patient
  Address
  City
  State
  Zip Code
  Home Phone
  Cell Phone
  Work Phone
  Can we leave appointment reminders? Yes     No    
  If yes, preferred phone number?
  Parent/Guardian E-mail address
not required
  Can we contact you via e-mail? Yes     No    
Primary Insurance Information
Please provide us with your current insurance information and present your current insurance card(s). This helps ensure that we correctly bill your insurance for you.
  Patient Insurance Information Health Insurance Claim     Worker's Compensation Claim     Auto Accident Claim     None    
  Date of Injury (if applicable)
  Name of Insurance Company
  Insured's Name
  Relationship to Patient
  ID/Policy #
  Group #
  Effective Date
  Insured's Employer
  Employer's Phone Number
  Employer Address
  City
  State
  Zip Code
  Insured's Date of Birth
  Sex Male     Female    
Secondary Insurance Information
  Name of Insurance Company
  Insured's Name
  Relationship to Patient
  ID/Policy #
  Group #
  Effective Date
  Insured's Employer
  Employer's Phone Number
  Employer Address
  City
  State
  Zip Code
  Insured's Date of Birth
  Sex Male     Female