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Outpatient Registration

Physician's Order
Do you have a written order from your physician? *

Personal Information (Step 1 of 5)
Contact Person *
Phone Number *	() - Ext:
Relationship to Patient *
Patient Information
First Name *
Middle Initial
Last Name *
Social Security Number	- -
Date of Birth *	mm/dd/yyyy
Gender *
Address *

City *
State *
Zip Code *
Daytime Phone *	() -
Evening Phone	() -
E-Mail *
Confirm E-Mail *
Emergency Contact *
Phone Number *	() -
Relationship to Patient *

Clinical Information (Step 2 of 5)
If available, please scan physician's order and attach here

Ordering Physician
Last Name *
First Name *
Middle Initial
Office Phone *	() - Ext:
Office Fax	() -
Address *

City *
State *
Zip Code *
Ordered Tests/Reason for Visit
Test(s) * Click on a category to the right to display the tests available for that category.	Cardiology Echocardiogram: 2D Echo Echocardiogram: Stress Echo Nuclear Stress Test: Adenosine Nuclear Stress Test: Dobutamine Nuclear Stress Test: Dual Isotope Sestamibility Nuclear Stress Test: Holter Monitors Specify # of hours:: Nuclear Stress Test: Thallium Stress Test (GXT) Stress Test: Treadmill Stress Test (GXT) CT Scan Abdomen attention to:: Abdomen and Pelvis Brain attention to:: Cervical Chest With or Without Contrast:: Facial Bones Internal Auditory Canals Lower Extremity Right, Left or Both Legs:: Lumbar Neck (skull Base to Thoracic Inlet) Orbits Paranasal Sinuses Pelvis Posterior Fossa Sacrum Temporal Bone Thoracic Upper Extremity Righ, Left or Both Arm:: EEG (Electroencephalogram) EEG Lab 2 Hr Glucose 3 Hr Glucose Mammography Annual Screening or Baseline Screening Bilateral Diagnostic (this is not a screening) Bilateral Mammo with Ultrasound if needed Bone Density Scan (Dexa Scan) Implant Diagnostic Implant Screening Unilateral Diagnostic ( this is not a screening) Right or Left Breast:: Unilateral Mam with Ultrasound if needed Please Specify Left or Right Breast: Women's Wellness Package Includes Mammogram & Dexa Scan: MRI Abdomen attention to:: Brain attention to:: Cervical Chest Internal Auditory Canal ( iac's) Lower Extremity Hips, Femur, Knee, Lower Leg, Ankle, Foot: Lumbar MRA (angios) Body Part:: Neck Orbits Pituitary Thoracic Upper Extremity Shoulder,Humerus,Elbow,Forearm,Wrist,Hand : Nuclear Medicine Adenosine Dual Isotope Bone Scan Attention to:: Bone Scan: Three Phase Attention to:: Dobutamine Dual Isotope Hepatobiliary Scan With or Without CCK:: Liver Scan Lung Scan MUGA Scan Parathyroid Scan Renal Scan Thallium Dual Isotope Other Unlisted Test Please specify below: Radiology (exams that are scheduled) Arthrogram w/MRI to Follow Part of Body:: Barium Enama Double Contrast Barium Enema Full Column Esophogram Histosalpingogram Is your Dr performing exam: Yes or No: IVP With or Without Tomogram:: Mylogram w/CT to Follow What part of Spine:: Small Bowel UGI with Air Contrast Voiding Cystourethrogram Xrays not listed above do not need to be scheduled Respiratory Bronchial Provocation PFT w/Bronchodilator Basic or Complete:: Pulmonary Function Test (PFT) Basic or Complete:: Ultrasound Aorta (Abdominal Aorta) Breast: Bilateral (Both) Breast: Unilateral (Left) Breast: Unilateral (Right) Duplex Carotid (Neck) Extremity (Bilateral) Extremity (Left) Extremity (Right) Gall Bladder Infant Kidneys Kidneys Kidneys & Urinary Bladder Liver OB Growth OB Gyn Please indicate: Twins, Limited, 1st, 2nd or 3rd trimester: Pancreas Pelvic (Male) Pelvic w/Transvaginal (female) Popliteal Foss Right or Left:: Scrotum Spleen Thyroid Transvaginal Urinary Bladder Vein Map Bilateral, Left, or Right: Venous (Bilateral) Venous (Left) Venous (Right)
Diagnosis as written on your order *

Scheduling Information (Step 3 of 5)
We will do our best to accommodate the date and time you request, but all tests may not be offered at each location or at the times you have requested. We will call you to arrange an alternate time and date if necessary.
Preference *	First available Preferred day of week/time of day
First Choice * Please be advised that not all tests are performed on all days.
Second Choice *
Third Choice *
Preferred EMHC Location * Please be advised that not all tests are performed at all locations.
Comments or Special Instructions

Complete Your Outpatient Test Request
At this point you have submitted all of the required information. If you would like to save time at your office visit, you can now preregister online by entering insurance and other optional information. If you choose not to provide this information at this time you will be required to provide this information at your office visit. Would you like to preregister now?

Insurance Information (Step 4 of 5)
Insurance Type *
Name of Insurance Company or Self Pay *
Subscriber Name *
Subscriber Date of Birth *	mm/dd/yyyy
Policy Number/SSN *
Group Number *	Usually located on the back of your insurance card
Benefits Phone Number *	() -
Precertification Phone Number *	() -
Billing Address *

City *
State *
Zip Code *

Other Information (Step 5 of 5)
Employment Status *
Retirement Date, if Applicable	mm/dd/yyyy
Employer Name
Employer Phone	() -
Employer Address

Employer City
Employer State
Employer Zip Code
Worker's Compensation/Auto Insurance (if applicable)
Do these tests pertain to a worker's compensation or auto accident claim? *	Yes No

Demographic Information
Ethnicity
Marital Status

Insurance Name *
Policy/Claim Number *
Date of Accident	mm/dd/yyyy
Time of Accident
Location of Accident
Employer at Time of Accident
Adjuster's Name
Adjuster's Phone	() -
Address

City
State
Zip Code

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