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| Family Physician: |
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| *Appointment Date: |
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| *Appointment Time: |
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| If Pregnant, Expected Due Date: |
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| *Reason For Visit / Diagnosis: |
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| *Type of Service: |
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| *Patient First Name: |
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| *Patient Middle Name: |
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| *Patient Last Name: |
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| *Date of Birth: |
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| *Gender: |
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| *Marital Status: |
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| *Smoker: |
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| *Mailing Address: |
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| *City: |
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| *State: |
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| *Zip Code: |
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| *Daytime Phone: |
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| *Evening Phone: |
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| Cell Phone: |
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| Social Security Number: |
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| Employment Status: |
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| Employer: |
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| Employer Phone: |
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| Name of Spouse: |
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| Spouse Employment Status: |
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| Spouse Employer: |
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| Spouse Employer Phone: |
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| Name of Mother: |
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| Name of Father: |
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Who should we notify in case of Emergency?
(Preferably a spouse, parent or other relative) |
| *Emergency Contact Name: |
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| *Relationship: |
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| *Contact Home Phone: |
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| Contact Work Phone: |
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| Contact Cell Phone: |
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| Many insurance companies and health plans will not pay healthcare claims for patients who fail to adhere to pre-certification or notification requirements. Be sure to check your insurance card or with your employer for pre-certification requirements before receiving services. Patients are financially responsible to Inland for all services, including penalties imposed for non-compliance with insurance or plan requirements. |
| *Primary Health Plan Carrier: |
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| Insurance Company Number One |
| Name of Insurance: |
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| Address: |
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| City: |
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| State: |
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| Zip Code: |
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| Phone: |
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| Subscriber Name: |
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| ID Number : |
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| Group Name or Number: |
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| Precertification Number: |
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| Insurance Company Number Two |
| Name of Insurance: |
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| Address: |
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| City: |
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| State: |
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| Zip Code: |
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| Phone: |
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| Subscriber Name: |
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| ID Number : |
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| Group Name or Number: |
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| Precertification Number: |
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If you elect to electronically submit a completed Pre-registration Form or any other information to Arkansas Methodist Medical Center through this website, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or omissions in the data you provide. You agree to release and hold Arkansas Methodist Medical Center and its affiliates (including its directors, officers, employees, agents, and representatives) harmless from any and all liability or cause of action arising from the interception, access, or use by a third party of any information submitted electronically by you through this website and from any errors or omissions in the data you provide. Additionally, the provision of any information to Arkansas Methodist Medical Center by you through this web site, including a completed Pre-registration Form, does not create or constitute any relationship between you Arkansas Methodist Medical Center, its affiliates, or any of the physicians on its staff, to which any privilege may attach.
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Family Services 
