SURGICAL PATIENT INFORMATION
Please provide the requested information prior to your scheduled surgery. (These forms are not for individual physician practices.)
All required fields are denoted with an asterisk (). You may save your progress at any time.
*This field is required
Emergency Contact Details
Insurance Secondary Details
Please complete the lower portion of this form and return it to the Patient Pavilion with the other pre-admission information.
This information will expedite the completion of your baby's birth certificate. We need to complete the birth certificate before your discharge and it needs to be filed with the Department of Vital Statistics within five days after the baby's birth. If you do not have all the information completed when you return the form, please have it available when we come to do the birth certificate.
Within 24 hours after your baby is born, someone will come to your room to ask for the baby's full name. If the bottom part of this form is completed, all that will be required is verification of the information and your signature on the information sheet and the registration form. If you are unmarried and the baby's father is going to sign, it is important that he come in within 48 hours after the birth.
Before you leave the hospital, you will be given a hospital birth certificate for your family records. We will file the birth certificate with the State of Florida, Department of Vital Statistics. In order to obtain a copy of the birth registration, you should contact the Indian River County Health Department.
NOTE: If you are being discharged from the hospital and still have not been contacted regarding the birth certificate, please notify a nurse so it can be taken care of.
Please provide us the requested information. All required fields are denoted with an asterisk (). You may save your progress at any time.
ADDITIONAL PATIENT AND PROCEDURE INFORMATION
INFORMATION ABOUT SPECIFIC CONDITIONS
Please Enter name of your primary care physician, family physician, internist or pediatrician.
Do you have any other health care providers who are currently providing services to you?
1. Patient Rights handout provided?
2. Do you or significant others / care givers(s)have special need or disability?
3. May we share your name, general condition, religious affilaltion and room number with those who ask(i.e friends who call, clergy, etc.)?
4. In the event of a medically necessary circumstance, will you accept a blood transfusion or blood products?
5. Do you have a patient representative/support person?
b. If inpatient, may we notify your personal representative/friend/family that you have been admitted?
(PERSONAL REPRESENTATIVE IS PRESENT) if YES or DECLINES, document name date and time of notification:
If UNABLE TO DETERMINE(follow policy and document actions taken in Paragon.Notification of admission Completed.
If NO, call assigned nurse for follow up and request nurse document notification and document same in Paragon.
6. For EMERGENCY ROOM visits, may we notify your Family Physician that you have been seen in the Emergency Room?
May we notify your family physician that you have been admitted?
If YES or UNABLE TO DETERMINE (follow policy to derlermine which physician to notify), list name(s) of doctor(s) notified and document in Paragon.
If NO, enter DNNP in Notes in Paragon.
7. Visitation Rights given
8. Advance Directive Brochure and From Provided. Document status in Paragon.
9.Immunization - We report immunizations to the state and Federal goverment (If you would like to optout of the reporting please circle)
10. Are you participating in a Clinical Research Study?
11. If first encounter or when updated, provide Notice of Privacy Practices (Entered in Paragon)
12. If Medicare inpatient, Message of Medicare Rights notice given:
13. Privacy Password Provided (last 4 digits of account number):
Please provide us the requested information (If Known or If applicable).
If you are a self-pay patient, you are receiving this notice because you do not currently qualify for assistance under the Cleveland Clinic Financial Assistance Policy, and you may be responsible for some or all of the charges incurred for the above date of service.
If you are one of the following types of insured patients:
You are receiving this notice because you may be responsible for some or all of the charges incurred for the above date of service.
By signing below, you acknowledge that: