Online Pre-Registration
Registering on-line is an easy way to register any time - day or night. Gathering information before your arrival date will help to minimize delays in your registration. Be assured that all information is confidential. Although you are submitting insurance information, you will still need to bring your insurance cards with you to the hospital when receiving services. If you have any questions while filling out this form, feel free to call. You can also preregister over the phone. Please Note: Please allow three (3) days before your appointment for your pre-registration form to be processed. If there is less than three days before your appointment, please call express registration at (740) 374-1751. You must fill in all required fields for the form to be accepted. If the field does not apply, enter "NA" or if you are unsure what to put in, enter "??".
* denotes required fields.
Appointment Information:
*Anticipated Appointment Date:	Open the calendar popup. << < March 2010 > >>   S M T W T F S 10 28 1 2 3 4 5 6 11 7 8 9 10 11 12 13 12 14 15 16 17 18 19 20 13 21 22 23 24 25 26 27 14 28 29 30 31 1 2 3 15 4 5 6 7 8 9 10		*Have you been a patient here before?	YesNo
*Facility:	Marietta Memorial HospitalWayne Street		*Reason for visit:
Patient Information:
*Last Name:			*Address1:
*First Name:			Address2:
Middle Name:			*City:
Maiden Name:	(if married)		*State:	select -Select One- Alaska Alabama Arkansas Arizona California Colorado Connecticut D.C. Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming
			*Zip:
			County:	(e.g. Washington,Monroe..)
*Primary Phone Number:			*Marital Status:	select -Select One- Divorced Married Never Married Separated Single Widowed
Secondary Phone Number:			*Ethnic Origin:	select -Select One- Asian African American Caucasian Hispanic Native American Other(Not Listed)
Email:			*Religion:	select -Select One- Baptist Catholic Christian Episcopal Greek Orthodox Hindu Islam Jehovah Witness Judaism Lutheran Mormon/Latter day Saints None Orthodox Other – not listed Presbyterian Protestant Seventh Day Adventist
			*Name of church:
*Gender:	MaleFemale
*Date Of Birth:	Open the calendar popup. << < March 2010 > >>   S M T W T F S 10 28 1 2 3 4 5 6 11 7 8 9 10 11 12 13 12 14 15 16 17 18 19 20 13 21 22 23 24 25 26 27 14 28 29 30 31 1 2 3 15 4 5 6 7 8 9 10
*Social Security Number:
*Advance Directive/ Living Will?	YesNoUnknown
Employment Information:
*Employment Status:	select -Select One- Newborn Child (Student) Full-Time Part-Time Retired Unemployed		*Address1:
*Employer Name:			Address2:
Date of Retirement:	Open the calendar popup. << < March 2010 > >>   S M T W T F S 10 28 1 2 3 4 5 6 11 7 8 9 10 11 12 13 12 14 15 16 17 18 19 20 13 21 22 23 24 25 26 27 14 28 29 30 31 1 2 3 15 4 5 6 7 8 9 10		*City:
Occupation:			*State:	select -Select One- Alaska Alabama Arkansas Arizona California Colorado Connecticut D.C. Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming
			*Zip:
*Phone Number:
Extension:
Primary Emergency Contact Information:
*Last Name:			Check this box if Address is same as that of the Patient.
*First Name:			*Address1:
Middle Name:			Address2:
			*City:
			*State:	select -Select One- Alaska Alabama Arkansas Arizona California Colorado Connecticut D.C. Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming
*Phone Number:			*Zip:
			County:	(e.g. Washington,Monroe..)
Social Security Number:
*Relation to Patient:	BrotherSisterMotherFatherFriendSpouseOther
Employment Information:
*Employment Status:	select -Select One- Newborn Child(Student) Full-Time Part-Time Retired Unemployed		*Address1:
*Employer Name:			Address2:
Date of Retirement:	Open the calendar popup. << < March 2010 > >>   S M T W T F S 10 28 1 2 3 4 5 6 11 7 8 9 10 11 12 13 12 14 15 16 17 18 19 20 13 21 22 23 24 25 26 27 14 28 29 30 31 1 2 3 15 4 5 6 7 8 9 10		*City:
Occupation:			*State:	select -Select One- Alaska Alabama Arkansas Arizona California Colorado Connecticut D.C. Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming
			*Zip:
*Phone Number:
Extension:
Secondary Emergency Contact Information:
*Last Name:			Check this box if Address is same as that of the Patient.
*First Name:			*Address1:
Middle Name:			Address2:
			*City:
			*State:	select -Select One- Alaska Alabama Arkansas Arizona California Colorado Connecticut D.C. Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming
*Phone Number:			*Zip:
			County:	(e.g. Washington,Monroe..)
*Relation to Patient:	BrotherSisterMotherFatherFriendSpouseOther
Employment Information:
Phone Number:
Extension:
Primary Insurance Information:
*Does the patient have Primary Insurance?	YesNo		*Name of Insurance Company:
*Phone Number:
*Policy Holder's Name:			Check this box if Mailing Address is same as that of the Patient.
*Policy Number:			*Address1:
*Policy Holder's Social Security Number:			Address2:
*Policy Holder's Date Of Birth:	Open the calendar popup. << < March 2010 > >>   S M T W T F S 10 28 1 2 3 4 5 6 11 7 8 9 10 11 12 13 12 14 15 16 17 18 19 20 13 21 22 23 24 25 26 27 14 28 29 30 31 1 2 3 15 4 5 6 7 8 9 10		*City:
			*State:	select -Select One- Alaska Alabama Arkansas Arizona California Colorado Connecticut D.C. Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming
*Group Name:			*Zip:
*Group Number:
*Relation to Patient:	BrotherSisterMotherFatherFriendSpouseOther
Secondary Insurance Information:
*Does the patient have Secondary Insurance?	YesNo		*Name of Insurance Company:
*Phone Number:
*Policy Holder's Name:			Check this box if Mailing Address is same as that of the Patient.
*Policy Number:			*Address1:
*Policy Holder's Social Security Number:			Address2:
*Policy Holder's Date Of Birth:	Open the calendar popup. << < March 2010 > >>   S M T W T F S 10 28 1 2 3 4 5 6 11 7 8 9 10 11 12 13 12 14 15 16 17 18 19 20 13 21 22 23 24 25 26 27 14 28 29 30 31 1 2 3 15 4 5 6 7 8 9 10		*City:
			*State:	select -Select One- Alaska Alabama Arkansas Arizona California Colorado Connecticut D.C. Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming
*Group Name:			*Zip:
*Group Number:
*Relation to Patient:	BrotherSisterMotherFatherFriendSpouseOther
Physician/Clinical Information:
*Ordering Physician's Name:			*Family Physician's Name:
*Ordering Physician's Phone:			*Family Physician's Phone: