On-line pre-registration is available up to 48 hours before
your test or procedure.
  
Please call (678) 604-1055  if your test or procedure is scheduled 
in the next 48 hours and you want to pre-register. Thank you.  

     Henry Medical Center
     1133 Eagle's Landing Parkway
     Stockbridge, GA 30281
  
     Pre-Registration Form

     ADMISSIONS/REGISTRATION SERVICES (678) 604-1004

     FAX FORMS TO: (678) 604-5586
Physician Name:
Physician Telephone:
Planned Date of Service:
 e.g. 07/17/05
Type of Outpatient Service:

Labor & Delivery
Lab

Xray
Surgery
Other
Patient's Name:   Sex:  
Address:   Race:  
County of Residence:   Marital Status:  
City:   State:   Zip:   Date of Birth:  
Home Telephone #:   Work Telephone #:  
Cell Phone #:   SSN #:  
Email Address:  
Emergency Contact Name:   Telephone #:  
Cell Phone #:  
Guarantor/Responsible Party:   Date of Birth:  
Guarantor's Employer:   SSN #:  
Home Telephone #:   Work Telephone #:  

Primary Insurance
Insurance Company:   Insured's Name:  
Insurance Telephone #:   Insured's Date of Birth:  
Insured's SSN #:   Insured's relationship to patient:  
Policy #:   Group #:  
  Effective date:  

Secondary Insurance
Insurance Company:   Insured's Name:  
Insurance Telephone #:   Insured's Date of Birth:  
Insured's SSN #:   Insured's relationship to patient:  
Policy #:   Group #:  
  Effective date:  

Someone from Henry Medical Center may contact you to clarify the information submitted.
Please bring your physician's order for any test, your driver's license and your insurance card.