1. Pre-registration Information

    Thank you for submitting your registration information prior to your visit.
    IMPORTANT: FILLING OUT THIS FORM DOES NOT SET YOUR PST APPOINTMENT, BUT INSTEAD ALLOWS YOU TO CHOOSE YOUR PREFERRED DATE AND TIME.
    YOU WILL BE CONTACTED BY PST TO CONFIRM THIS DATE/TIME IS AVAILABLE.

    At this time we are only accepting online pre-registration for out-patient surgery otherwise your pre-registration must be received at least five business day prior to your PST visit date. If you are within one business day of your visit, please complete the registration at PST.

    PST appointment hours are 7:30 am - 7:30 pm, Monday - Friday

  2. What is the date of your procedure:
  3. Preferred PST appointment date:
  4. What is your admitting Doctor's name:
  5. What is your admitting Doctor's phone number:
    xxx-xxx-xxxx
  6. What is your family Doctor's name:
  7. What is your family Doctor's phone number:
  8. When would you like to be contacted?(*)
    Please select a date when we should contact you.

  9. Patient Information

  10. Last Name
  11. First Name
  12. Middle Initial
  13. Street Address
  14. City:
  15. State:
    Invalid Input
  16. Zip
  17. Home
  18. Cell:
  19. E-mail:
  20. Date of Birth:
  21. Age
  22. Sex:
  23. Marital Status
  24. Language:(*)
    Please select from the drop down list.
  25. These forms can be completed in the admitting office and added to your medical records.
  26. Employment Status:
  27. Employer:
  28. Address:
  29. Job Title:
  30. Work Phone Number:

  31. Part II

  32. Do you have any medication allergies (please list):
  33. List who to contact in case of emergency:(*)
    This is a required field.
  34. Address:
  35. Phone Number:(*)
    This is a required field.
  36. Cell:
  37. Second emergency contact:
  38. Relationship:
  39. Address:
  40. Phone Number:
  41. Cell:

  42. Part III

    Insurance Information

  43. Do you have insurance?
    Invalid Input
  44. Do you have seconday insurance?
  45. If no, please select your method of payment.
  46. Insurance Company Name
  47. Address (claims address is listed on the back of your insurance card:
  48. Phone (customer service number listed on the back of your insurance card):
  49. Policy Holder (whose name is the insurance in):
  50. Policy Number:
  51. Policy Holder Date of Birth:
  52. Policy Holder Address:
  53. Policy Holder Phone Number:

  54. Medicare/Medicaid

  55. Are you covered by Medicare?
  56. If yes, Please provide your name as it appears on your card.
  57. Medicare Number:
  58. Part A Hospital Effective Date:
  59. Part B Medical Effective Date:
  60. Company Retired From:
  61. Retired Date:
  62. Are you covered by Medicaid?
  63. Medicaid Number:
  64. Effective Date
  65. State:
    Invalid Input
  66. Name as it appears on your card:

  67. Part IV

    Baby's Insurance

  68. Will the baby be covered under insurance?
    If yes, have you notified the insurance company?
  69. If no, please select your method of payment.
  70. Insurance Company Name
  71. Address (claims address is listed on the back of your insurance card:
  72. Phone (customer service number listed on the back of your insurance card):
  73. Policy Holder (whose name is the insurance in):
  74. Policy Number:
  75. Policy Holder Date of Birth:
  76. Policy Holder Address:
  77. Policy Holder Phone Number:
  78.   
1000 Montauk Highway
West Islip, NY 11795

phone 631.376.4444

Catholic Health Services
A Magnet® Designated Hospital