Surgical Preadmission Information Form

24451 Health Center Drive
Laguna Hills, CA 92653
(949) 452-3546

Have you previously had services at Saddleback Medical Center? Yes No

VISIT INFORMATION

Physician:

Date of Service:

Procedure Being Done:

PATIENT INFORMATION

Last Name:

First Name:

Middle Int:

Suffix:

Date of Birth:

Social Security #:

Maiden Name:

MAILING ADDRESS

Street:

Apt #:

City:

State:

Zip Code:

Phone Number:

PERSONAL INFORMATION

Legal Sex: Male Female Other

Race

Ethnicity

Religious Preference

Primary Language

Will you need an interpreter Yes No

Advance Directive Power of Attorney Yes No on file at Saddleback Medical Center

EMPLOYMENT INFORMATION

Occupation:

Employer:

Employer Address:

City:

State:

Zip Code:

Phone Number:

EMERGENCY CONTACT

Name:

Relationship:

Phone Number:

Cell:

Work:

Is the reason for your visit due to a workers compensation or auto accident? Yes No

If you answered Yes, please fill out parts A & B

If you answered No, please just fill out part A

PART A

Are you 65 years of age or older? Yes No

Retirement Date (MM/YY)

Are you disabled? Yes No

Date of Disability (MM/YY)

Do you have End Stage Renal Disease? Yes No

Start date of Dialysis (MM/YY)

PRIMARY INSURANCE

Subscriber Name:

Social Security #

Date of Birth:

Insurance Company:

ID #

Group #

Insurance Phone #

Occupation:

Employer:

Phone:

SECONDARY INSURANCE

Subscriber Name:

Social Security #

Date of Birth:

Insurance Company:

ID #

Group #

Insurance Phone #

Occupation:

Employer:

Phone:

ADDITIONAL INSURANCE

Subscriber Name:

Social Security #

Date of Birth:

Insurance Company:

ID #

Group #

Insurance Phone #

Occupation:

Employer:

Phone:

PART B

Workers Compensation

Date of Accident:

Where:

Name of Employer (at time of accident):

Contact Person:

Name of Insurance Company:

Claim Number:

Adjustor Name:

Adjustor Phone:

Email Address:

PHOTO OF DRIVER'S LICENSE

PHOTO OF INSURANCE CARD (FRONT)

PHOTO OF INSURANCE CARD (BACK)

If you have questions, feel free to contact the Admissions Office at MemorialCare Saddleback Medical Center at (949) 452-3546

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