Appointment/Admitting Pre-Registration Form
Please complete the following appointment/admitting pre-registration form as completely as possible to expedite your request.
* Red Indicates Required Information
Appointment/Admitting Pre-Registration
Expected Appointment/Admitting Date: (M/D/Y) *
/
/
2020
2021
2022
2023
Admission to *:
Inpatient
Maternity
Surgical
EEG
EKG
Respiratory Care
Radiology
Nuclear Medicine
Rehab
Wound Healing
Education
Radiation Oncology
Sleep Center
Other
General Admission Information
Admitting/Referring Physician:
Diagnosis:
Planned Procedure:
Primary Care Physician:
Primary Physician Phone:
(
)
Maternity Only
Expected Due Date:
Last Menstrual Cycle:
Baby Insurance:
Primary
Secondary
Both
Mom Dr:
Baby Dr:
Patient Information
Patient Name:
Last* First*
MI
Patient D.O.B. *:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
Mailing Address:
Addr *:
City *:
State *:
ZIP *:
Primary Phone *:
(
)
Work Phone:
(
)
Cell Phone:
(
)
EMail Addr:
Patient SSN:
-
-
(Last 4 only)
Gender:
Female
Male
Other
Marital Status:
Single
Married
Divorced
Separated
Widowed
Emergency Contact Information
Contact Name:
Last* First*
MI
Relationship *:
Relationship of contact to patient *:
Primary Phone *:
(
)
Work Phone:
(
)
Cell Phone:
(
)
EMail Addr:
Additional Patient Information
Do you have a living will?
Yes
No
Specify your religious affiliation here (optional):
If you would like race included in your patient profile, specify it here (optional):
Have you ever been a VMC patient?
Yes
No
If yes, please select one of the following:
Inpatient
Outpatient
Emergency
Do you have a Healthcare Power of Attorney?
Yes
No
If you require an interpreter, please select one of the following:
Arabic
Burmese
Cambodian
Chinese
Chinese/Cantonese
Chinese/Hmong
Chinese/Mandarin
Chinese/Shanghai
English
Ethiopian
Filipino
Filipino/Bicol
Filipino/Ilocano
Filipino/Tagalog
Filipino/Visayan
French
German
Greek
Hearing Impaired
Hindi
Italian
Japanese
Korean
Laotian
Other
Polish
Punjabi
Romanian
Russian
Samoan
Somali
Spanish
Taiwanese
Ukranian
Unknown
Vietnamese
Specify if Other:
Insurance Information
Primary Insurance
Provider:
Select or specify other ...
Aetna-US Healthcare
CIGNA
DSHS
First Choice Health
Medicare
Molina Health Care
PacifiCare of Washington
Premera Blue Cross
United Health Works
Regence Blue Shield
Other - Please Specify
Policy Number:
Group Number:
Provider Address:
Addr:
City:
State:
ZIP:
Policy Holder:
Relation to Patient:
Employer:
Holder Date of Birth:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
Holder Contact Information
Home Phone:
(
)
Work Phone:
(
)
Cell Phone:
(
)
EMail Addr:
Secondary Insurance
Provider:
Select or specify other ...
Aetna-US Healthcare
CIGNA
DSHS
First Choice Health
Medicare
Molina Health Care
PacifiCare of Washington
Premera Blue Cross
United Health Works
Regence Blue Shield
Other - Please Specify
Policy Number:
Group Number:
Provider Address:
Addr:
City:
State:
ZIP:
Policy Holder:
Relation to Patient:
Employer:
Holder Date of Birth:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
Holder Contact Information
Home Phone:
(
)
Work Phone:
(
)
Cell Phone:
(
)
EMail Addr:
If you are done filling out the form please click the "Submit Request" button at the top to submit your request. Thank you!