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A Resource Guide for Patients & Visitors

Patient Pre-Registration

Welcome to the Scottsdale Healthcare online patient pre-registration form. Use this form to save time by submitting your pre-registration information prior to your admittance. Please do not use this form to submit pre-registration information for a normal doctor's visit.
 

All fields in bold indicate information necessary for on-line pre-registration. If you do not have all of the information indicated in bold, do not proceed. The system will not accept your registration. To complete your pre-registration in a timely fashion, Scottsdale Healthcare must obtain a copy of both the front and back sides of your insurance card. Please note your full name and date of admission on the copy and fax it to the appropriate facility:

Attention: Pre-Registration Coordinator

 Facility  Fax#
  Osborn Medical Center OB/Maternity 480-882-4031
  Shea Medical Center OB/Pediatrics 480-323-3137

 

Scottsdale Healthcare recognizes the confidential nature of the information you are about to submit. For this reason, you are now working in a new secured window. Your browser will indicate this by displaying a padlock in the bottom right corner of your browser window. You can feel secure knowing that the information you are providing will be kept in strict confidence and exceeds the Internet standards necessary for transmitting this type of information. Once you have submitted your pre-registration form you will receive an e-mail confirmation and confirmation number. Keep this number for your records. Thank you for choosing Scottsdale Healthcare.

Below is you Pre-Registration confirmation number. Please write this number down and keep it for your records.


Patient's details


Parent/Guardian (required if patient is under 18 years old):

Procedure details

Ordering Physician

Primary Care Physician

Employer details

If you are not employed, please answer "none", "n/a", or "not applicable" in all required employment related fields.

Spouse/Nearest Relative

Insurance Information

The following information can be found on your insurance card.
If you do not have insurance, please answer "none", "n/a", or "not applicable" in all required insurance fields.

Primary Insurance

Insured's Detail

Insured's Employer Details

Secondary Insurance

Insured's Detail

Insured's Employer Details

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