Pre-Register Form Please enable JavaScript in your browser to complete this form.Surgeon *Please Select Allender, Brian Anderson, Charles Bascom, Thomas Bock, Kimberly Brackebusch, Joyce Christensen, Nathan Clark, Katelyn Cusati, Daniel DeHaas, David Freeman, Jennifer Garrett, Audrey Gerhards, Sara Haugen, Julie Henderson, Winnie Herrmann, David Hutton, Daniel Ingalls, Nichole Jewett, Paula Kelel, Kristy Kokkino, Andrew Kollmorgen, Christine Kosek, Peter Kyle, Brooke MacColl, Colin McCourt, Michael Modeste, Kevin Roundy, Neil Seidman, Craig Stenshoel, Tamara Tucker, Todd Tufariello, Jennifer Yang, Edmund Yang, KathleenDate of SurgeryName *Date of Birth *Address *Sex *MFOtherCity/State/Zip *Social Security *Phone * HWCReferring Physician *Phone *HWCPrimary Physician *Email *Emergency Contacts (Please provide 2)Contact Name *Contact Name *Relationship *Relationship *Phone *Phone *Employment InformationEmployedUnemployedRetiredOtherOccupationEmployer AddressExplanation (if other)City/State/ZipEmployerPhoneGuarantorSame as patientNameGuarantor EmployerDate of BirthSocial Security #PhoneAddressAddressCity/State/ZipCity/State/Zip Primary InsuranceInsured Name *Relationship to Insured *Social Security *Insurance Company Name *Date of Birth *Insurance ID# *AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSecondary InsuranceInsured Name Relationship to InsuredSocial Security Insurance Company NameDate of BirthInsurance ID#Address Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDemographic InformationPlease note that this survey is a requirement by The State of Oregon Department of Health for Ambulatory Surgery Centers and is being performed in accordance with the State of Oregon Department of Health. These questions are strictly confidential and will only be used for state reporting purposes. Please check the answer that applies to you. EthnicityWhite/EuropeanBlack/AfricanHispanic/LatinoNative AmericanOtherRaceWhiteBlack/African AmericanIndian/Alaskan NativeAsian Bi-racialNative American/Pacific IslanderOtherReligionChristianJewishMuslimHinduBuddhistNoneOtherEmailSubmit
