(508) 828-7000

Existing Patients

Our programs and services include:

Online Existing Patient Pre-registration

Bem-vindo ao Hospital Morton & Medical Center existentes Online paciente pré-registo.

Com sucesso o pré-registo on-line, você será capaz de ir diretamente para o departamento onde o teste está sendo realizado.

Este serviço de pré-registo está actualmente limitada a determinados serviços / departamentos de testes.

Sua nomeação já deve ser agendada. A data de sua nomeação deve ser entre 2-30 dias após a data de submeter este formulário.

Patient Information
Date of Scheduled Appointment
MM/DD/YY
Service/Department
What type of test do you have an appointment for?		 CT SCAN
MRI
MAMMOGRAPHY
BONE DEX
COLONOSCOPY
GASTROSCOPY
Ordering Physician
What Doctor ordered this test? Last name, first name
Primary Care Physician
Last name, First 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
Sex Male     Female    
Race Black     White     Asian     Native American     Hispanic    
Social Security Number
Last 4 digits
Employment Area
Employment Changes
Has your employer's information changed since the last time you pre-registered online? If no, please skip to insurance information.		 Yes     No    
  Employment Status
  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
  Street Address
  City
  State
  Zip
Five Digit Zip Code
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.