Appointment Information


Diagnosis
Date Symptoms Began (required)
Ordering Doctor (required)
Primary Family Physician
Are you Diabetic?
YesNo
Do you use tobacco products?
YesNo
Check if injury was an accident
 

[group group-accident]

Accident Information

Date of Accident:
Accident Type:

[group group-accident-type-auto]

Insurance Company Information

Insurance Company
Address:
City

Phone

State:

Zip:

[/group]

[group group-accident-type-work]

Employer Information

Employer Name
Address:

City

Phone

State:

Zip:

[/group]

[group group-accident-type-liability]

Responsible Party Information

Responsible Party
Address:
City

Phone
State:

Zip:

[/group]

[group group-accident-type-other]

Responsible Party Information

Responsible Party
Address:
City

Phone
State:

Zip:

[/group]

[/group]


Patient Information

First Name (required)
MI
Last Name (required)
Suffix
Address (required)
County (required)
Email (required)
Home Phone (required)
Alt/Cell Phone
Social Security Number (required)
Marital Status
SingleMarriedDivorcedWidowed
Race (required)
Are you an American Citizen?
YesNo
[group group-not-american]
Country of Citizenship

[/group]
Would you like a clergy visit?
YesNo
[group group-denomination]
Denomination

[group group-other-denomination]
Your denomination (Other)

[/group]
Employment Status

[group group-full-part-time]

Employment Information

Occupation

Employer Name
Address
Phone

[/group]
[group group-retired-company]

Company Retired From

[/group]


Is the responsible party information the same as the patient?
YesNo

[group group-responsible-party-other]

Responsible Party Information

First Name (required)
MI
Last Name (required)
Suffix
Address (required)
County (required)
Email (required)
Home Phone (required)
Alt/Cell Phone
Social Security Number (required)
Responsible Party Employment Status

[group group-responsible-full-part-time]

Responsible Party Employment Information

Occupation

Employer Name
Address
Phone

[/group]
[group group-responsible-retired-company]

Company the Responsible Party Retired From

[/group]

[/group]


Emergency Contact Information

Emergency Contact Name

Relation to Patient
Emergency Contact Phone

Do you have insurance?
YesNo

[group group-insurance]

Insurance Information

Insurance Company Name (required)
Addresss
Phone

Relation to Patient (required)

Policy Number (required)
Group Number (required)
 
Check here if you have Secondary Insurance

[group group-insurance-secondary]

Secondary Insurance Information

Secondary Insurance Company Name (required)
Addresss
Phone

Relation to Patient (required)

Policy Number (required)
Group Number (required)

[/group]

[/group]

The names of patients who are registered at EAMC appear in a daily directory. You have the option of having your name removed from the directory for privacy reasons. Please understand that removing your name means that if anyone calls for you, if flowers are delivered for you, or if someone comes to try to visit you at the hospital we will tell them that you are not here

 
Check here if you do not wish for your friends and family to know you are at EAMC
(remove your name from the EAMC directory)
Check here if we can correspond with you via this email address