Pre-Registration: Maternity

Maternity Pre-Registration

Kindly complete this form to begin the pre-registration process for your maternity stay at Doctors Hospital.
This pre-registration form is intended to pre-register for your use of Doctors Hospital's facility for your delivery.

DISCLAIMER: DEADLINE: If your estimated delivery date/delivery date is less than four (4) days away, we urge you to pre-register in-hospital.

If you have already completed this form and your nature of delivery has changed, you do not have to complete another one. Kindly contact us to update us via our email.

DOCTORS HOSPITAL PREREGISTRATION DEPARTMENT

Telephone Contact(s):

Direct Pre-Registration Line: (242)-302-4748 (Mondays-Fridays, Hours: 9 a.m. - 5 p.m.)

Main Patient Registration Line: (242)-302-4734

Email: preregistration@doctorshosp.com

Documents

Please be prepared to upload, if necessary, the following documents for your pre-registration.
- Patient Government Issued Photo ID
- Insurance Card (if applicable)
- Admission Slip (from your physician's office)
- Guarantor Government Issued Photo ID (if applicable)
- Depending on your selections, these documents may be required in order to complete this pre-registration form.

Patient Demographics

Please review your answers before moving on to the next page.
YesNo
YesNo
Full Name:*

First NameMiddle NameLast Name
Date of Birth:*

MonthDayYear
Marital Status:*
NIB Number:*
If you do not have a NIB number, enter "0"
Email Address (will be used for important correspondence regarding pre-registration):*

Confirmation Emailexample@example.com
Home Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number:
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer Information
EmployedSelf-EmployedUn-Employed
Name of Employer:*
Job Title:*
Employer Address:*

Street Address

Street Address Line 2

City/SettlementState/Province/Island

Postal / Zip Code (if none, enter "0")Country
Employer Contact Number:*
Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contacts

Please indicate the persons to contact in the case of an emergency.
Primary Contact
Full Name:*

First NameMiddle NameSurname
Relationship to Patient:*
Home Number:*
Format: (000) 000-0000.
Cell Phone Number:
Format: (000) 000-0000.
YesNo
Address:*

Street Address

Street Address Line 2

City/SettlementState/Province/Settlement

Postal / Zip Code (if none, enter "0")Country
Secondary Contact

It is a requirement that each patient has two (2) emergency contacts on file.
Full Name:*

First NameMiddle NameSurname
Relationship to Patient:*
Home Number:*
Format: (000) 000-0000.
Cell Phone Number:
Format: (000) 000-0000.
YesNo
Address:*

Street Address

Street Address Line 2

City/SettlementState/Province/Settlement

Postal / Zip Code (if none, enter "0")Country

Delivery Information

Nature of Delivery & Estimated Delivery Date
Please select your nature of delivery:*
Please indicate the nature of delivery stated on your admission slip from your physician.
Physician Details
Name of Physician:*
Please enter the correct name of your physician as written on your admission slip.
Name of Physician Office:
Estimated Delivery Date

Please select your Estimated Delivery Date (EDD) as stated on your admission slip from your physician. You may select any time, but please select the correct EDD.
Estimated Delivery Date:*

Method of Payment
Please select your method of payment for your delivery: *

Guarantor Agreement

The Guarantor must be an individual 18 years or older.
YesNo
Guarantor Details

Please complete the following information of the person who is financially responsible for the patient (other than the patient), pertaining to the indicated respective healthcare service(s) in this submission. Person must be 18 years or older.
Guarantor's Name:*

First NameLast Name
Guarantor's NIB#:*
Relationship to Patient:*
Guarantor's Email Address:*

Confirmation EmailPlease enter the email address twice to confirm that the correct email address was entered.
Cell Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Home Number:
Please enter a valid phone number.Format: (000) 000-0000.
Guarantor's Signature:*

Clear
By signing this, I hereby agree to all the terms and conditions listed above.

Method of Payment

Insurance Details
YesNo
YesNo
Primary Insurance Carrier
Name of Insured:*
Relationship to Patient:*
Insured's Employer:*
Name of Group
Primary Insurance Carrier:*
Insurance Company
Certificate Number:*
Member Identification Number
Secondary Insurance Carrier
Name of Insured:*
Relationship to Patient:*
Insured's Employer:*
Name of Group
Secondary Insurance Carrier:*
Insurance Company
Certificate Number:*
Member Identification Number
Digital Insurance Form

Kindly complete and submit this form. Failure to complete your insurance form will result in a hold on your account until it has been successfully received with the appropriate signatures.
Digital Insurance Form

Please complete the following form below:
Please ensure that "Patient's Signature" and "Insured's Signature" have your signatures. Failure to do will result in a hold on your account.
- Please click "Start Filling" to complete the form.
- Once you click "Submit", please wait for the Confirmation Page to appear, confirming that your submission was successful before moving on to the next page (you will see this confirmation page once you click "Submit"):
EXAMPLE:
YesNo

File(s) Upload

Please ensure that each file is legible.
Patient Government-Issued Photo Identification:*

Accepted File Formats: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
Cancelof
Admission Slip (from your physician's office):*

Accepted File Formats: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png **You will be quoted based on the nature of delivery stated in this slip**
Cancelof
Insurance Card(s):*

Accepted File Formats: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
Cancelof
Guarantor Government Issued Photo ID:*

Accepted File Formats: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
Cancelof

Terms & Conditions

Please read the below terms carefully.
Patient Signature:*

Clear
By signing this, I hereby agree to all the terms and conditions listed above.
Guarantor's Signature:*

Clear
By signing this, I hereby agree to all the terms and conditions listed above.
Conditions of Admissions Form

The completion of this form is a requirement for all maternity patients to complete prior to being admitted for services.
Conditions of Admissions Form
- Please click "Start Filling" to complete the form.
- Please note to also initial at all fields under "THIS SECTION IS TO BE INITIALED IF THE PATIENT IS ADMITTED TO HOSPITAL". Your document will not be accepted as completed if the document is missing signatures/initials.**
- Issues with signing initials:
  - Please initial in the far left side of the initial box.
- Once you click "Submit", please wait for the Confirmation Page to appear, confirming that your submission was successful (you will see this confirmation page once you click "Submit"):
EXAMPLE:
YesNo

Email Correspondence
After you submit your registration form, you will immediately receive two (2) emails from us with important information.

It is important that you check your email to ensure that you have these emails from our team.
Should be Empty:

Maternity Pre-Registration

Documents

Patient Demographics

Employer Information

Emergency Contacts

Primary Contact

Secondary Contact

Delivery Information

Physician Details

Estimated Delivery Date

Method of Payment

Guarantor Agreement

Guarantor Details

Method of Payment

Primary Insurance Carrier

Secondary Insurance Carrier

Digital Insurance Form

Digital Insurance Form

File(s) Upload

Terms & Conditions

Conditions of Admissions Form

Email Correspondence