Array ( [0] => 02 [1] => 49 ) Health Central - Pre-Registration
Pre-Registration

Thank you for pre-registering for your scheduled appointment at Health Central. You may submit this application online or print and fax to Health Central Registration 407-253-1677. For more information, please call 407-296-1190.

Click here for a printable version.

Patient Information:
Patient Name
Street Address
City State Zip
Area Code / Telephone - -
Social Security Number
Date of Birth -
Race
Marital Status Sex
Email
Guarantor Information (If not patient):
Name
Street Address
City State Zip
Area Code / Telephone - -
Social Security Number
Date of Birth -
Race
Marital Status Sex
Relation to Patient
Patient Employer Information:
Patient's Employer
Patient's Employer's Address
City State Zip
Work Telephone - -
Full Time Part Time
Retired? Date -
Disabled? Date -
Self Employed? Yes No
Student? Yes No
Emergency Contact Information:
Emergency Contact Name
Emergency Contact Address
City State Zip
Phone - -
Alternate Phone - -
Relation to Patient
Primary Insurance Information:
Insurance Name
Customer Service Phone - -
Claims Address
City State Zip
Policy Number
Group Number
Pre-certification required Yes No
(If unknown, please call ins. to find out.)
Insured Person: (If not Self)
Name
SSN
Date of Birth -
Sex
Relation to Patient
Employer
Secondary Insurance Information:
Insurance Name
Customer Service Phone - -
Claims Address
City State Zip
Policy Number
Group Number
Pre-certification required Yes No
(If unknown, please call ins. to find out.)
Insured Person: (If not Self)
Name
SSN
Date of Birth -
Sex
Relation to Patient
Employer
If Military:
Branch
Status:
Pay Grade:
Procedure Diagnosis: Ordering Doctor:
Appointment Date - Time: :
We may need to call you for additional information in order to complete the Pre Registration Process.
Form may be submitted online or faxed to 407-253-1677.