Doctors Hospital Rehabilitation [Patient]

  • Doctors Hospital

    Rehabilitation Pre-Registration Form

  • Thank you for choosing Doctors Hospital Rehabilitation Services!

    Please read the following form carefully to complete your pre-registration.

     

    Kindly allow for one (1) business day for a response from the Rehabilitation Team!

     

  • Required Documents

  • Please be prepared to upload:

    • Patient Government Issued ID
    • Patient Insurance Card (if applicable)
    • Personal Representative (Parent, Adult Child, Legal Guardian, etc.) Government Issued ID

     

  • Is the person completing this form a Patient or Patient Representative?

  • Patient Details

  • Date of Birth:*
     - -
  •  -

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  • Emergency Contacts

  • Next of Kin

  •  -
  • Does this person share the same address as the patient?

  • Person to Notify

  •  -
  • Does this person share the same address as the patient?

  • Method of Payment

  • Have your documents been successfully submitted and approved by the National Insurance Board (NIB)?

  • Please ensure that the National Insurance Board Occupational Health & Safety unit has approved your rehabilitation sessions with a 'Letter of Guarantity'. 

  • Does the patient have dual insurance coverage with the same insurance company?

  • Primary Insurance

  • Primary Insurance Carrier:

  • Do you have your insurance policy number:

  • Secondary Insurance

  • Secondary Insurance Carrier:

  • Do you have your insurance policy number:

  • Patient Health & Physician Details

  • Rehabilitation Location & Visit Date Preference

    Available options: Cable Beach, Collins Ave & Home
  • Please select a preferred date and time for your visit:

  • Please note that a date and time will be confirmed with you by a DH associate before your appointment.

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