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

Patient Details
Patient Name:

First NameLast Name
Date of Birth:*

DayMonthYear
Date
Patient NIB #:
Sex:
Telephone Contact:

Area CodePhone Number
Email Address (please enter the email address in both fields):

Confirmation EmailPlease ensure the correct email address is entered.
Home Address:

Street Address

Street Address Line 2

CityState/Province/Island

Postal /P.O. Box/ Zip Code

Patient Health & Physician Details
Name

PrefixFirst NameLast Name
Please enter any medical conditions that you/the patient has been diagnosed with (e.g. High Blood Pressure, Diabetes, Congestive Heart Failure, etc.)

Rehabilitation Location & Visit Date Preference

Available options: Cable Beach, Collins Ave & Home
Kindly select a preferred location from the list below:
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.

File Upload
Patient Identification:

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

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

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

Doctors Hospital