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Patient Registration
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Layout
Please choose the type of registration:
*
Labor & Delivery
Surgery
Date of Surgery
*
Surgeon
*
Please select your obstetrician from the list:
*
OB/GYN
Dr. Melissa Bailey
Dr. Shruti Benjamin
Dr. Suzette Boyd
Dr. Laura Bradley
Dr. Laura Cline
Dr. Quanita Crable
Dr. Gary Duncan
Dr. Gabriele DuVernois
Dr. Karen Edwards-Key
Dr. Dennis Eisenberg
Dr. Holly Eliason
Dr. Malathi Ellis
Dr. Alice Fa
Dr. Berry Fleming
Dr. David Fong
Dr. Keith Grisham
Dr. Madhuri Gudipaty
Dr. Jennifer Gulick
Dr. Jeffrey Hermann
Dr. Catherine Holt
Dr. Nora Hsu
Dr. Kristen Innes
Dr. Eric Jacoby
Dr. Ralph Joseph
Dr. Hina Kahn
Dr. Christine Ku
Dr. Kayla Mapps
Dr. Jordan Mitchell
Dr. Sridevi Panchamukhi
Dr. Carrie Patterson
Dr. Jon Ricks
Dr. Angela Stoehr
Dr. Tina Thai
Dr. Julie Vu
Dr. Alisa Ward
Dr. Jonathan Weinstein
Dr. Leslie Welborne
Dr. Tania White-Jackson
If you do not see your obstetrician listed, they do not have privileges at Baylor Scott & White Medical Center - Frisco.
Patient Information
Patient's Name
*
First
Middle
Last
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Patient's Date of Birth
*
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Patient's Gender:
*
Female
Male
Patient's Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Layout
Patient's Phone Number:
*
Patient's Marital Status
*
Please choose one:
Married
Single
Divorced
Widow/Widower
Race
*
Please select one:
African American
Asian or Pacific Islander
Caucasian
Hispanic
Latino
Native American
Other
Unknown
Are you of hispanic origin?
*
Yes
No
Patient's Email Address
*
Social Security Number
*
Patient's Religious Preference:
*
Please select one:
Baptist
Buddhist
Catholic
Church of Christ
Christian
Church of Latter Day Saints
Christian Science
Episcopal
Greek Orthodox
Islam
Jewish
Jehovah's Witness
Lutheran
Methodist
Nazarene
Non-Denomination
None
Other
Patient Employment
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Is the patient employed?
*
Yes
No
Patient's Employer
*
Patient's Employer Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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Patient's Employer Phone Number:
*
Patient's Occupation
*
Patient's Employment Status
Full-Time
Part-Time
Unemployed
Retired
Active Military Duty
Student
Other
Next of Kin
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Patient's Next of Kin:
*
Does Patient's Next of Kin have a different address than the patient?
*
Yes
No
Next of Kin Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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Next of Kin Phone Number:
*
Next of Kin relationship to patient:
*
Is your person to notify the same as your Next of Kin?
*
Yes
No
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Person to Notify:
Relationship to Patient:
Person to Notify Address:
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Person to Notify Phone Number:
Guarantor
Is the patient a minor?
*
Yes
No
Guarantor Name:
First
Last
Guarantor Date of Birth:
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Guarantor Address:
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Layout
Guarantor Phone Number:
Guarantor Social Security Number
Guarantor Email:
Guarantor Relationship to Patient:
Gurantor Employer Name
Guarantor Employer Address:
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Layout
Guarantor Employer Phone Number:
Guarantor Occupation
Guarantor Employment Status:
Full-Time
Part-Time
Unemployed
Retired
Active Military Duty
Student
Other
Insurance Provider Information:
Is the Primary Insurance Provider Medicare?
*
yes
no
Insurance Provider
*
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Medicare ID #
*
Insurance ID #:
*
Insurance Group #:
*
Policy Holder Name:
*
First
Last
Does Policy Holder have a different address to the patient?
*
Yes
No
Policy Holder Address:
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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Policy Holder Date of Birth
*
MM
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DD
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1921
1920
Policy Holder Social Security:
*
Policy Holder Relationship to Patient:
*
Is the Policy Holder Employer Different to the Patient Employer?
*
Yes
No
Policy Holder Employer Name:
Policy Holder Employer Address:
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Is there a Secondary Insurance Provider?
*
Yes
No
Secondary Insurance Provider:
Layout
Secondary Insurance Provider ID#:
Secondary Insurance Provider Group#:
Secondary Insurance Policy Holder Name:
First
Last
Secondary Policy Holder Address:
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Layout
Secondary Insurance Policy Holder Date of Birth:
MM
1
2
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5
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DD
1
2
3
4
5
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2020
2019
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2017
2016
2015
2014
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2011
2010
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2008
2007
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2004
2003
2002
2001
2000
1999
1998
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1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
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1982
1981
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1920
Secondary Insurance Policy Holder Relationship to Patient:
Secondary Policy Holder Employer:
Secondary Policy Holder Employer Address:
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Baby's Insurance
Is the baby's insurance provider different to the patient's?
Yes
No
Baby's Insurance Provider
Layout
Baby's Insurance Provider ID#:
Baby's Insurance Provider Group#:
Baby's Insurance Policy Holder Name
First
Last
Baby's Insurance Policy Holder Address:
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Layout
Baby's Insurance Policy Holder Date of Birth:
MM
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2
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DD
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2
3
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1920
Baby's Insurance Policy Holder Social Security:
Baby's Insurance Policy Holder Relationship to Patient:
Additional Patient Information
Layout
Do you have any sensory or physical impairments?
*
Yes
No
Physical or Sensory Impairments
Layout
Expected Delivery Type:
*
Vaginal
C-Section
Recognizing that text message communication is not a completely secure method of communication, do you consent to receiving text messages regarding your account?
*
Please select one:
Yes
No
Date of patient's last menstrual period
*
MM
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2
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8
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12
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2016
2015
2014
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2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
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1984
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1981
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Primary Care Physician
Primary Care Physician
*
Primary Care Physician Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Primary Care Physician Phone Number:
*
Due Date
*
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Do you have Advance Directive documents? (check all that apply)
*
Advance Directive
Medical Power of Attorney
Living Will
DNR
Mental Health Directive
None
Location of these documents:
Would you like to enroll in CommonWell Health Information Exchange?
*
Yes
No
CommonWell is a not-for-profit trade association that breaks down technological and process barriers that inhibit effective health data exchange. The organization works to drive new innovations and to make health data more accessible with the aim of improving health outcomes. CommonWell works to help patients and providers get better access to health records and better coordinate care.
Driver's License Number (for CommonWell Registration):
In the last 14 days have you traveled outside of the United States?
*
Please choose:
Yes
No
In the last 14 days, have you been asked by a healthcare provider to self-quarantine or had close contact with anyone while they were quarantined?
*
Please choose:
Yes
No
In the last 12 months, did you stay overnight in a healthcare facility outside of the United States?
*
Please choose:
Yes
No
Do you have fever, cough, or shortness of breath?
*
Please choose:
Yes
No
In addition to fever, cough, and shortness of breath, do you have night sweats or unexplained weight loss?
*
Please choose:
Yes
No
Do you have at least TWO of these symptoms? Fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or NEW loss of taste or smell?
*
Please choose:
Yes
No
Have you or anyone you had close contact with been diagnosed with a laboratory confirmed case of:
COVID-19
MERS
SARS
Unsure
No
Your Signature
*
Clear Signature
Please sign to confirm the information provided for registration.
Submit