Pre-registration Form

Instructions
1. Please complete all information on the form.
2. If you require assistance in completing this form, please call the Business Office at 605-696-9000.
3. Please remember to bring your insurance cards and an identification card when you arrive at the hospital.


Patient Information


Maiden/Other Name
mm/dd/yyyy
xxxxxxxxx
(xxx) xxx-xxxx

(xxx) xxx-xxxx

If yes, please bring a copy when admitted

Spouse/Next of Kin


(last name, first name, middle name)
mm/dd/yyyy
xxxxxxxxx
(xxx) xxx-xxxx
(xxx) xxx-xxxx

If no, please complete all information in this section
(Person who can make medical decisions for you if you are unable)
(xxx) xxx-xxxx
(xxx) xxx-xxxx

Guarantor


1. One Person in household to receive billing statement.
2. If patient is 18 years or older they will be listed as guarantor.
3. If the guarantor is different please complete guarantor section.

If no, please complete all information in this section
(last name, first name, middle name)
mm/dd/yyyy
xxxxxxxxx
(xxx) xxx-xxxx
(xxx) xxx-xxxx
Other then next of kin
(xxx) xxx-xxxx
(xxx) xxx-xxxx

Insurance Information


(xxx) xxx-xxxx

(xxx) xxx-xxxx

mm/dd/yyyy
mm/dd/yyyy

mm/dd/yy
Please check applicable box
mm/dd/yyyy

Accident/Injury/Work Compy/Information (if applicable)

mm/dd/yyyy