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Pre-Registration
We want to make your registration at St. Rita’s as easy as we can. You can pre-register by filling out the information below and e-mailing it back to us.** If you prefer, you may also fax the completed form to us at 419-996-5421. If you pre-register, you will be able to just check in at patient registration, and then go directly to your service.

Please have your information to us as soon as possible and no later than the night (12hrs) before you are coming. You will receive an e-mail confirmation when your pre-registration is complete.

**Your information comes over a secure line and can only be opened by authorized staff. 		Core Values
Pre-Registration
Alert*Denotes Required Fields
Patient Information


*Are you the patient?
Yes No
If you are not the patient, what is your relation to the patient?

If you are not the patient, what is your name?

*Inpatient or Outpatient?
Inpatient Outpatient
Living Will/Durable Power of Attorney

Church

County

*First Name

*Middle Name

*Last Name

Maiden/Previous Name

*Address:

Address 2:

*City:

*State:

*Zip:

E-mail:

*Date of Birth:
(mm/dd/yyyy)
*Social Security Number:
(xxx-xx-xxxx)
Do not have Social Security Number
Phone:

*Gender:
Male Female
Race:

*Marital Status:

Emergency Contact Name:

Emergency Contact Phone:

Emergency Contact Relationship:

Patient's Employer:

*Is Insurance Through Employer?:
Yes No

Procedure


*Date of Service or Procedure:
(mm/dd/yyyy)
*Doctor Ordering the Procedure:

*Family Doctor:

Diagnosis/Reason for Visit: (500 Characters Max.)
 Policy Holder Information


*Policy Holder's Name:

*Address:

Address 2:

*City:

*State:

*Zip:

*Date of Birth:
(mm/dd/yyyy)
*Social Security Number:
(xxx-xx-xxxx)
*Relationship to the Patient:


Employer Information


*Employment:
I am Employed I am Unemployed
*Employer:

*Employer Address:

Employer Address 2:

*Employer City:

*Employer State:

*Employer Zip:


Patient's Insurance Information


*Insurance:
I have Insurance (Note secondary insurance information in comments box if needed.)
I do not have Insurance
*Insurance Company Name:

*Address:

Address 2:

*City:

*State:

*Zip:

Group Number On Insurance Card:

ID Number on Insurance Card if Different than Social Security Number:

Additional Comments: (500 Characters Max.)


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