Welcome to South Nassau

Online Registration Form

Do you have an Advance Directive? YES NO If YES, is it on file with SNCH? YES NO Is this visit related to: Motor Vehicle Accident? YES NO Work Related Accident? YES NO If YES, please see Registrar for additional required form.


Patient Last Name	First Name	MI
Date of Birth	Age	Sex M F
Patient Address		Social Security #
City	State	Zip Code
Place of Birth	Marital Status M D S W	Race
Religion	Ethnicity	Patient Phone
Mother's Maiden Name	Father's First Name
Preferred Language	Translator Needed? YES NO
Emergency Contact	Relationship	Telephone #
Next of Kin Name	Next of Kin Telephone #


Policy Holder Employer Name	Employer Telephone #
Employer Address
Patient's Retirement Date	Spouse's Retirement Date
Disabled? YES NO	Retired? YES NO
Primary Reason(s) for Visit	Family Doctor		Telephone #


1st Insurance:
Policy Holder Name	Policy #	Group #
Relationship to Pt.	Policy Holder DOB	Insurance Billing Address

2nd Insurance:
Policy Holder Name	Policy #	Group #
Relationship to Pt.	Policy Holder DOB	Insurance Billing Address

3rd Insurance:
Policy Holder Name	Policy #	Group #
Relationship to Pt.	Policy Holder DOB	Insurance Billing Address
PLEASE HAVE PHOTO I.D. AND ALL INSURANCE CARDS AVAILABLE.