(508) 828-7000

Patient Pre-Registration

Our programs and services include:

Patient Pre-registration

Welcome to Morton Hospital's Online Pre-registration.

By successfully Pre-registering Online, you will be able to go directly to the department where your test is being performed.

This pre-registration service is currently limited to certain services/testing departments.

Your appointment must already be scheduled. The date of your appointment should be between 2 - 30 days from the date you submit this form.

Patient Information
Date of Scheduled Appointment
MM/DD/YY Test should be at least two days from now.
Service/Department
What type of test do you have an appointment for?		 CT SCAN
MRI
MAMMOGRAPHY
BONE DENSITY
ULTRASOUND
COLONOSCOPY
GASTROSCOPY
Ordering Physician
What Doctor ordered this test? First and last name.
Primary Care Physician
First and Last Name
Patient Full Name
Last Name, First Name
Street Address
Full Street Address or P.O. Box including Apt # if applicable
City
State
Zip Code
Five digit zip code
Telephone
Area Code and 7 Digit Number
Date of Birth
MM/DD/YY
Marital Status Single     Married     Divorced     Separated     Widowed    
Sex Male     Female    
Race Black     White     Asian     Native American     Hispanic    
Social Security Number
Last 4 digits
  Religion
Religious Affiliation
Allergies
Please include any food or drug allergies or type NONE
Latex Allergies
Are you allergic to Latex?		 Yes     No    
Are You Employed or a Student? Yes     No     Student     Self Employed     Retired    
  Employer's or School's Name
Please answer if employed or a student. Must be completed if the source of payment is Worker's Comp
  Employer's or School's Street Address
  City
  State
  Zip Code
Five Digit Zip Code
  Occupation
  Retirement Date
Must be filled in if you have Medicare
Person to Notify Information
Name Of Person To Notify In Case Of An Emergency
Street Address
City
State
Zip Code
Five Digit Zip Code
Telephone
Relationship to patient
Additional Contact Telephone #
Cell phone or Business Phone Please indicate which. Or type NONE
Guarantor Information
  Name Of Person Responsible For Bill
To be filled out only if patient is a minor
  Street Address or P.O. Box
  City
  State
  Zip Code
Five Digit Zip Code
  Telephone
Area Code and 7 Digit Number
  Relationship To Patient
  Social Security Number
Last 4 digits
  Employer's Name
  Employer's Street Address
  City
  State
  Zip
Five Digit Zip Code
  Employer Phone Number
Area Code Plus 7 Digit Number
  Responsible Party's Occupation
Insurance Information
Source of Payment Health Insurance     Worker's Comp     Auto Insurance     Self Pay    
Insurance Changes
Has your insurance information changed since the last time you pre-registered online? If no, please skip to contact information.
  Name of Insurance #1
Enter the name of your health insurance as it appears on your card here. If you have no insurance, enter none here and on the other required fields.
  Policy #
  Group #
  Policy Holder
Name on the card or person who is paying for insurance through their employer
  Insurance Address
Usually located on the back of the card. Mail claims to:
  Name of Insurance #2
If you have more than one insurance, please list your second insurance here
  Policy #
  Group #
  Policy Holder
Name on card or person who is paying for insurance through their employer
  Insurance Address
Usually located on the back of the card. Mail claims to:
  Name of other Health Insurances
If you have any additional insurances, please give us the name of the insurance, policy #, policy holder and address
Contacting Patient
Morton Hospital has permission to reach me if the information here does not match my records. I understand that if I do not give MH permission to reach me, my pre-registration may need to be repeated at the hospital. I would like to be reached by:		 Phone
Email
Not at all
  Email Address
If you have requested that we contact you by email in the question above, enter your email address here
Please type the letters you see to help us minimize SPAM.