Please fill out our Pre-Registration form below. Pre-Registration Form Patient Information First Name Middle Initial Last Name Have you ever been registered/or seen with a different name? YesNo Give Name Email Address (Please enter none if you don't have an email address) Check here if you would like to receive health and wellness updates from Anaheim Regional Medical Center. Patient Address City State Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana International Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming Zip Code Phone Number Cell Phone Sex Select Male Female Date of Birth Place of Birth Social Security (not required) -- Marital Status Select Single Married Divorced Widowed Race Select White Black Native American/Eskimo/Aleut Asian/Pacific Islander Other Unknown Decline to Answer Ethnicity Select Hispanic or Latino Not Hispanic or Latino Decline to Specify Preferred Language Select English Spanish Cantonese Mandarin Vietnamese Other Other Religious Affiliation Employment Status Select Full Time Part Time Unemployed Retired Occupation Employer Phone # Employer Name Employer Address Admission Information Are You a Returning Patient? YesNo Ordering Physician Name (Click to search our physicians) Primary Care Physician / Family Doctor Chief Complaint Expected date of conception (for labor and delivery) Expected date of procedure (for non-maternity) Expected Admission Time Please list your Current Medication Information Type of Procedure Select Radiology (X-ray, MRI, CT-scan) OB Normal Delivery OB C-Section GI LAB - EGD GI LAB Colonoscopy Inpatient Surgery (Staying overnight in hospital) Outpatient Surgery (leaving same day) Spouse or Guarantor Information Spouse First Name Spouse Last Name Relationship Spouse or Guarantors Social Security # -- Spouse or Guarantor’s Address Same as Patient Address City State Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana International Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming Zip Code Telephone Same as Patient Phone Spouse or Guarantor's Employment Status Method of Contact Best Way to Contact You Best Time to Contact You If there is a financial liability (i.e. co-payment, deductible, etc) what is your preferred method of payment? Emergency Contact Information Contact Person First Name (Please enter none if you don't have an emergency contact) Contact Person Last Name Relationship to Contact Address Phone Number MEDICARE Patients Medicare Number Patient Retirement Date Spouse Retirement Date Spouse Date Of Birth Accident / Injury Date of Injury Time of Injury Injury Locations Work Auto Other Claim # Very Brief Accident Description Adjuster's Name Adjuster's Phone Number Primary Insurance Subscriber Name (Please enter self-pay if you don't have primary insurance) Subscriber Social Security # (not required) -- Subscriber Date of Birth Relationship to Patient Name of Insurance Insurance Phone # Billing Address Policy / Member # Group # Employer Employer Phone # Employer's Address Secondary Insurance Subscriber Name Subscriber Social Security # -- Subscriber Date of Birth Relationship to Patient Name of Insurance Insurance Phone # Billing Address Policy / Member # Group # Employer Employer Phone # Employer's Address Advanced Directive Advance Directive? YesNo If yes please bring to facility on date of service Submit Pre-Registration