Wound Care Registration

Wound Care Pre-Registration

Kindly complete this form to begin the pre-registration process for your wound care appointment at Doctors Hospital.
Kindly complete this form to pre-register for your wound care appointment.

Please note that you must have a scheduled appointment with our wound care clinic prior to pre-registering.

DEADLINE: This form must be submitted 48 hours prior to your date of service. DOCTORS HOSPITAL PREREGISTRATION DEPARTMENT Telephone Contact(s): Direct Pre-Registration Line: (242)-823-9875 (Mondays-Fridays, Hours: 9 a.m. - 5 p.m.) Main Patient Registration Line: (242)-302-4610/4734 Email: preregistration@doctorshosp.com

Documents

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

Injury Details

Please be specific with your responses.
Please indicate all injuries and corresponding body location separated by comma (e.g. Stitches Left Hand, Cut Right Index Finger, etc.)*

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:*
Gender:*
Age:*
National Insurance Number (NIB #: *
If you do not have an NIB Number, please enter '0'.
Email Address (will be used for important correspondence regarding pre-registration):*

Confirmation EmailPlease enter your email address twice to ensure it is the correct address.
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

City/SettlementState/Province/Island

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

Employer Information
EmployedSelf-EmployedUn-Employed
Name of Employer:*
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 Emergency Contact
Full Name:*

First NameMiddle NameLast Name
Relationship to Patient:*
Home Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number:
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Address:*

Street Address

Street Address Line 2

City/SettlementState/Province/Island

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

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

First NameLast Name
Relationship to Patient:*
Home Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number:
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Address:*

Street Address

Street Address Line 2

City/SettlementState/Province/Island

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

Method of Payment
Cash, Visa Debit, MasterCard, AmexInsuranceNational Insurance Board (NIB) - *WORK-RELATED*Company (with Doctors Hospital credited account)
Please state the name of the Company:*
YesNo
Please click the link below for the form for your employer/manager to complete and submit to the Occupational Health & Safety Unit National Insurance Board on Carmichael Road: Employer's Report on Accident at Work (B44 Form) DISCLAIMER: If this form is not correctly completed and turned into the Occupational Health & Safety Unit National Insurance Board on Carmichael Road before your appointment, you will not be covered by NIB.

Guarantor Agreement

The Guarantor must be a person the age of 18 years or older.
YesNo

Guarantor Details

Please complete the following information of the individual who is financially responsible for the patient, pertaining to the indicated healthcare service(s) sought out as a result of this form submission. Person must be 18 years or older.
NOTE: Please note that even though you,the patient, may pay off your account balance and/or all bills concerning services obtained for this submission, it is Doctors Hospital's policy that a Guarantor, other than yourself, is listed for your account.
Guarantor's Name:*

First NameLast Name
Guarantor's NIB #: *
Relationship to Patient*
Home Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number:
Please enter a valid phone number.Format: (000) 000-0000.
Guarantor's Email Address:*

Confirmation EmailPlease enter the email address twice to confirm that the correct email address was entered.
Guarantor's Signature: *

Clear
By signing this, I accept financially responsibility of the patient.

File(s) Upload

Please ensure that each file is legible.
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
Guarantor Issued Photo Identification (individual must be 18 years or older): *

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

Terms & Conditions

Please read the below terms and conditions carefully as it contains important information concerning your pre-registration.
Patient's Signature:

Clear
By signing this, I accept financially responsibility of the patient.
Guarantor's Signature:*

Clear
By signing this, I accept financially responsibility of the patient.

Email Correspondence
After you submit your pre-registration form, you will receive an email from us with important information regarding your pre-registration. It is important that you check your email to ensure that you have received an email from our team.
Should be Empty:

Wound Care Pre-Registration