Patient Registration Demographic Face Sheet - Olathe Medical Center printable pdf download

Patient Registration Demographic Face Sheet - Olathe Medical Center

Patient Registration Demographic Face-Sheet

□

YES

Have you been discharged from the hospital within the last 14 days.

□

YES

Have you been treated at Olathe Medical Center or Miami County Medical Center

within the last 3 years.

Patient Name:___________________________________________

First

Middle Init

Last

Date: _________

Time: ________ e-mail_______________________________________

(e-mail is used for patient satisfaction only. Help us improve our process).

Home phone: ________________ Cell phone: _______________

Address: _______________________________________________________________

SS#: _________________ DOB: _______________ Sex: _____ Race:________

Ethnicity: Hispanic or Not

Marital Status: M W S D

Family Physician: _____________________Referring Physician: __________________

Employer: _____________________Phone: _____________________

Employer Address: ____________________________Occupation: ________________

Guarantor if different from patient:

Name: ________________________________ DOB: __________________________

Address: ________________________________________Phone: _________________

Employer and address: ____________________________________________________

Employer phone number: _____________________________

Spouse/Parent/Relative as Emergency Contact:

Name: _______________________________ Relationship: ______________________

Marital Status: M S D W Sex: M F

Race: _________________

SS#: _____________________ DOB: ___________________

Address: _______________________________________________________________

Phone: _______________________ Cell Phone: ______________________________

Insurance:

Name: ___________________________ ID#: ________________________________

Can continue on the back side if needed to add another emergency name and phone #

Patient Registration Demographic Face Sheet - Olathe Medical Center