Sheldon

Text Size A A A

Patient Pre-Registration

You can speed up your registration upon arrival by pre-registering online. Please enter the information requested on the following pages as completely and as accurately as possible. It will take you about 5 minutes to complete this form. Form needs to be completed two business days prior to admission.

Remember, that upon your arrival at Sanford Sheldon, you will be asked to verify your registration information; a copy of your insurance card will be made, and you will be asked to sign authorization forms.

NOTE: Any information collected during the online pre-registration process is protected for your privacy and confidentiality.All information submitted is a confidential part of your medical record. This is a secure section of the web site where your information is kept secure and private.

If you have any questions concerning the completion of this form, please call (712) 324-5041.

 

PATIENT PRE-REGISTRATION FORM

Patient Information

Yellow Bar

(03/25/2017)
  Show Calendar

(03/25/2017)
  Show Calendar
 
characters remaining
 
 
 
 
 
 
 
 
 
 
*State:  
 
 
 
 
 
*Sex:  

 

 
 
 
 
*State:  
 

 
 
 
*State:  

 
 
 

Emergency Contact Information

Yellow Bar
 
 
 
 
 
 
 
State:  
 

 
 
 
 
 
 
 
State:  
 

Insurance Information
(A copy of your insurance card will be made upon registration.)

Yellow Bar
 
 
 
 
 
 
 
 
 
 
 
State:  
 
 
 
 
 
State:  
 

Supplemental Insurance Information

Yellow Bar
 
 
 
 
 
 
 
 
 
 
State:  
 
 
 
 
 
State:  
 

Is this Workman's Comp?  


(03/25/2017)
  Show Calendar
 
 
 
 
 
 
State:  
 

If this a motor vehicle accident?  


(03/25/2017)
  Show Calendar
 
 
 

 
 
 
 
 
 

Is this part of a reasearch grant?  

Are you eligible for Indian Health Benefits?  

 

Medicare Patients ONLY
(If you are not covered by Medicare, please skip this section.)

Yellow Bar
 
 
Do you have insurance through an employer?  


(03/25/2017)
  Show Calendar
Are you currently enrolled in a Medicare HMO?  

Are you a Veteran?  

Has the VA authorized or agreed to pay for this visit?  

Have you been hospitalized overnight within the last 60 days?