Pre-Registration: Surgical Day Case & Admissions

Pre-Registration: Surgical Day Cases & Admissions

Kindly complete this form to begin the pre-registration process for your admission or surgical procedure at Doctors Hospital
This pre-registration form is intended to pre-register for your use of Doctors Hospital's facility.
PLEASE NOTE: SURGICAL DAY CASE DEADLINE ONLY: This form must be submitted at least four (4) days prior to your date of service. We urge you to pre-register in-hospital if your surgery is less than four (4) days away.
- If you have already completed this form and your tentative surgery/admission date has changed, you do not have to complete another one. Kindly contact us to update us via email.
DOCTORS HOSPITAL PRE-REGISTRATION DEPARTMENT

Email: preregistration@doctorshosp.com

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

Main Patient Registration Line: (242)-302-4610/4734

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 (if applicable)
- Admission Slip (from your physician's office) -
- Guarantee of Payment Letter (if applicable) Requirements: Stamped, Dated, Signed on a letterhead Must include the date of surgery and the name of the surgical procedure
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
Age:*
Marital Status:*
NIB Number:*
If you do not have a NIB number, enter "0"
Gender:*
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:*
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 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 Contact

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

Hospital Visit Details

Admission or Surgery
Area of Service:*
Please select either "admissions" (overnight stay in hospital) or "surgery".
Name of Physician/Surgeon:*
Please enter the surgeon's/physician's first and last name.
Admitting Diagnosis:*
Please enter the diagnosis that you are being admitted to Doctors Hospital for.
Name of Procedure:*
Please enter the name of the procedure that you are having as stated on your admission slip.
Date of Admission/Surgery

Please select the correct date for your admission or surgery.
Please select the date and time of your surgery:*

Method of Payment
Please select your method of payment:*
Please state the name of the company:*
YesNo

Guarantor Agreement

The Guarantor must be an individual 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
Relationship to Patient:*
Guarantor's NIB #:*
Guarantor's Email Address:*

Confirmation EmailPlease enter the email address twice to confirm that the correct email address was entered.
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 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

NOTE: For children, the father's insurance is the primary insurance carrier.
Name of the Insured:*
Relationship to Patient:*
Insured's Employer:*
Name of Group Plan. If an individual plan, state ''individual'.
Primary Insurance Carrier:*
Name of the Insurance Company
Certificate Number:*
Member Identification Number
Secondary Insurance Carrier
Name of the Insured:*
Relationship to Patient:*
Insured's Employer:*
Name of Group Plan. If an individual plan, state ''individual'.
Secondary Insurance Carrier:*
Name of the 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.
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, 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
Guarantor Government-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
Guarantee of Payment Letter: *

Accepted File Formats: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
Cancelof
Other (e.g. Pre-Certification):

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 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 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.**
- 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

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

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

Pre-Registration: Surgical Day Cases & Admissions

Documents

Patient Demographics

Employer Information

Emergency Contacts

Primary Contact

Secondary Contact

Hospital Visit Details

Date of Admission/Surgery

Method of Payment

Guarantor Agreement

Guarantor Details

Method of Payment

Primary Insurance Carrier

Secondary Insurance Carrier

Digital Insurance Form

File(s) Upload

Terms & Conditions

Conditions of Admissions Form

Email Correspondence