Get Patient Registration Form - Floyd Memorial Hospital

The Patient Registration Form at Floyd Memorial Hospital is essential for ensuring that your personal and medical information is accurately recorded. Filling it out online can streamline your check-in process and improve your overall experience at the hospital.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by providing your last name and first name in the corresponding fields. If applicable, include your maiden name and middle name.
3. Fill in your complete address, including city, state, zip code, and county. Ensure all details are accurate to avoid any delays.
4. Enter your contact information, including home phone, work phone, and cell phone numbers.
5. Provide your email address for electronic communication and any pertinent notifications.
6. Indicate your gender and date of birth, along with your state of birth and social security number. Accuracy is important for record-keeping.
7. List your primary care physician's name and preferred pharmacy location to facilitate your medical care.
8. Select your marital status and provide your race and ethnicity from the options given.
9. Include your employer's information and its address to assist in verifying your employment status.
10. Designate an emergency contact along with their relationship to you and contact number. Specify the type of phone they can be reached on.
11. If applicable, provide your spouse's details including name, date of birth, social security number, and employment information.
12. Indicate how you heard about Floyd Memorial Hospital and your preferred method of communication.
13. If there is a responsible party different from the patient, fill in their full name, gender, date of birth, relationship to the patient, and contact information.
14. Provide your primary and secondary insurance information, along with the policy holder's details and relationship to you.
15. Review the acknowledgment statements regarding financial responsibility and medical record release, then provide your signature, relationship, and date.
16. Once completed, save your changes, and proceed to download, print, or share the form as needed.

Complete your Patient Registration Form online today for a seamless experience at Floyd Memorial Hospital.