A warm and friendly atmosphere.

ELLIOT 1-DAY SURGERY CENTER'S PRE-ADMISSION INFORMATION

Once you submit this form the page will be processed on the Elliot Hospital website, so the page will look quite different, this is by design. Your information is still secured and will be processed only by an Elliot 1-Day employee.

Preregister for your procedure at Elliot 1-Day Surgery Center.

If you have a test, procedure, or admission scheduled at Elliot Hospital, you can complete our secure preregistration form at your convenience. This will save you time on the day of your visit. Please fill out this form in its entirety. If any of the items marked with an asterisk (*) are left blank, this form will not submit. Please fill in as many items as possible - the more questions you answer for us, the better we are able to serve you.

Please note: On-line preregistrations are checked Monday-Friday, 8:00 AM - 4:30 PM. Please allow at least one full business day before your appointment for your preregistration form to be processed. If there is less than one full business day before your appointment, please preregister by calling (603) 663-5959.

*Indicates a required field / The form cannot be processed without the information requested in these fields

You have the right to be informed whether your referring physician has a financial or ownership interest in the Elliot 1-Day Surgery Center. For a complete listing of physician owners who provide services at Elliot 1-Day, please click here.

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Last Name* First Name* Middle Initial
Previous Name
Address* City*
State* ZipCode*
Home Phone Number* Date of Birth* (mm/dd/yyyy)
Social Security # (xxx-xx-xxxx)
Gender:* Marital Status*
Male Female

Scheduled Date of Procedure*

Surgeon:*
(mm/dd/yyyy)

Have you been a patient at
Elliot 1-Day Surgery Center?:
Primary Language*
Yes No

If this patient is a minor, please enter Minor in the Company field and 000-000-0000 for the Company Phone field below.

Employer Information

Company* Company Phone*
Address City
State Zip

 

Primary Care Physician:
First Name Last Name

 



Relationship to Patient
Last Name First Name Middle Initial
Address City
State Zip Code
Home Phone Number Date of Birth
Sex: Marital Status Social Security #
Male Female

Employer Information
Company Company Phone
Address City
State Zip

 

Alternate 
Emergency Contact

In the event of an emergency, please provide the name of a contact.

*Last Name *First Name Middle Initial *Home Phone Number
Work Phone Cell Phone

 

Insurance Info

Have you prepared a living will or durable power of attorney? Yes No *

If yes, what is the name of the invidual designated as holding the durable power of attorney?:

Last Name First Name
Relationship of this person to the patient
Address City
State ZipCode
Home Phone Number

 

 

Info on Test or 
Procedure

Is This Visit the Result of an Accident? Yes No
If yes, What is the Date of the Injury?

If This Visit is the Result of an Accident, What Was the Cause?

If 'Other,' Please Indicate Reason:

If the Accident was work related, please provide the name of employer at the time of the accident and the employer's phone:

 


Carrier Name Claim #
Carrier Address Carrier City
Carrier State Carrier Zip

 

Insurance Info

PRIMARY INSURANCE: (Please provide all information, even if you believe you entered it elsewhere on this form)

Please print information exactly as it appears on your insurance card.

*Name of Insurer *Is the Patient the Policy Holder?
Yes No
*Full Name of Policyholder *Policyholder's birthdate:
*Policyholder's Relationship to the Patient Insurance Company Address
City State
Zip Code Insurance Company Phone Number
Alternate Insurance Company Phone Number Group or Employer Name
*Group Number *ID or Policy Number

 

SECONDARY INSURANCE, IF ANY:(Please provide all information, even if you believe you entered it elsewhere on this form)

Please print information exactly as it appears on your insurance card.

Name of Second Insurer Is the Patient the Policy Holder?
Yes No
Full Name of Policyholder Policyholder's birthdate:
Policyholder's Relationship to the Patient Second Insurance Company Address
City State
Zip Code Second Insurance Company Phone Number
Alternate Phone Number Group or Employer Name
ID or Policy Number Group Number

Self pay, please call 603-663-5922 for a price quote

I have read and understand the summary of my rights as a patient of Elliot 1-Day, including the information about advance care directives.

Clicking this button will send your completed form to The Elliot. Please click it once only.