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

What is the date of your procedure:


Prefered PST appointment date:


What is your admitting doctor's name:


What is your admitting doctor's phone number: (*)


What is your family doctor's name:


What is your family doctor's phone number:


When would you like to be contacted? (*)

Please select a date when we should contact you.

Patient Information

Last Name


First Name


Middle Initial

This is a required field
Street Address

This is a required field.
City:

This is a required field.
State:
AlabamaAlaskaArizonaArkansas CaliforniaColorado ConnecticutDelaware Dist of ColumbiaFloridaGeorgia HawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Invalid Input
Zip


Home


Cell:


E-mail: (*)

Invalid email address.
Date of Birth:


Age

This is a required field
Sex:
MaleFemale
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Marital Status
SingleMarriedDivorced
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Language: (*)
Chinese (simplified)Chinese (traditional)EnglishFrenchGermanItalianJapaneseKoreanPortugueseRussianSpanish-AmerSpanish-Spain
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These forms can be completed in the admitting office and added to your medical records.

Employment Status:
EmployedUnemployed

Employer:

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Address:

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Job Title:

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Work Phone Number:

Part II

Do you have any medication allergies (please list):

Invalid Input
List who to contact in case of emergency: (*)

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Address: (*)

This is a required field.
Phone Number: (*)


Cell: (*)

This is a required field
Second emergency contact: (*)

Invalid Input
Relationship:

Invalid Input
Address: (*)

This is a required field.
Phone Number: (*)

This is a required field.
Cell: (*)

This is a required field

Part III

Insurance Information

Do you have insurance?
YesNoMedicare/Medicaid
Invalid Input
Do you have seconday insurance?
YesNo
Invalid Input
If no, please select your method of payment.
CashCheckCredit Card
Invalid Input
Insurance Company Name

This is a required field.
Address (claims address is listed on the back of your insurance card:


Phone (customer service number listed on the back of your insurance card):


Policy Holder (whose name is the insurance in):


Policy Number:

Invalid Input
Policy Holder Date of Birth:

Invalid Input
Policy Holder Address:

This is a required field.
Policy Holder Phone Number:

This is a required field.

Medicare/Medicaid

Are you covered by Medicare?
YesNo
Invalid Input
If yes, Please provide your name as it appears on your card.


Medicare Number:


Part A Hospital Effective Date:


Part B Medical Effective Date:


Company Retired From:

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Retired Date:

Invalid Input
Are you covered by Medicaid?
YesNo
Invalid Input
Medicaid Number:


Effective Date

Invalid Input
State:
AlabamaAlaskaArizonaArkansas CaliforniaColorado ConnecticutDelaware Dist of ColumbiaFloridaGeorgia HawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Invalid Input
Name as it appears on your card:

Invalid Input

Part IV

Baby's Insurance

Will the baby be covered under insurance?
YesNo
Invalid Input If yes, have you notified the insurance company?
If no, please select your method of payment.
CashCheckCredit Card

Insurance Company Name


Address (claims address is listed on the back of your insurance card:


Phone (customer service number listed on the back of your insurance card):


Policy Holder (whose name is the insurance in):


Policy Number:


Policy Holder Date of Birth:


Policy Holder Address:


Policy Holder Phone Number: