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Woodlawn Hospital

Fulton County Medical Clinic 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.
  Today's Date
Patient Information
* Patient Full Name
First Name, Middle Initial, Last Name
* Address
* City
* State
* Zip Code
  Email Address
  Can we contact you via e-mail? Yes     No    
  Home Phone
  Cell Phone
  Work Phone
  Date of Birth
  Sex Male     Female    
  Age
  Last 4 Digits of Social Security Number
Last 4 Digits of Social Security Number
  Marital Status Single     Married     Widowed     Divorced    
  Language English     Spanish     Other    
  Race Asian     Black     Indian/Native American     Pacific/Hawaiian     White    
  Hispanic Yes     No    
  Smoker Current every day     Current some a day     Former     Never    
  Patient Employed By
  Occupation
  Employer Address
  City
  State
  Zip Code
  Business Phone
  Student
If patient is a student, please list name of school.
  School Status Full Time     Part Time    
  Can we leave appointment reminders. Yes     No    
  If yes, preferred phone number?
Guarantor/Spouse Information (if not above)
  Name
  Relationship to Patient
  Phone Number
  Address
  City
  State
  Zip Code
  Date of Birth
  Sex Male     Female    
  Age
  Last 4 Digits of Social Security Number
Last 4 Digits of Social Security Number
  Employer
  Employer Address
Referring Physician
  Physician's Name
General Information
  Emergency Contact Name
  Date of Birth
  Relationship to Patient
  Address
  City
  State
  Zip Code
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 Information 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
  mployer's Phone Number
  Employer Address
  City
  State
  Zip Code
  Insured's Date of Birth
  Sex Male     Female