Registration

Medical Information/Miscellaneous
Name of Person Completing this Application*
First Last
Best Time to Reach You & Telephone Number or Email Address*
Appointment Date for Services*
Date Format: MM slash DD slash YYYY
Reason for Visit or Diagnosis*
Name of Test to be Performed
Referring Physician*
The name of the doctor that regularly provides your primary healthcare.
Advanced Directives*
Please check all that apply.
- None
- Living Will
- Power of Attorney
Organ Donor*
- Yes
- No
Smoker*
Please be advised, Coffee Regional Medical Center is a smoke-free facility and campus.
- Yes
- No
Is this admission/testing related to an accident?*
- Yes
- No
Date of Accident
Date Format: MM slash DD slash YYYY
Description of Accident
Please describe the accident below. For example, was it a motor vehicle accident, slip and fall in your home or at a business, etc.? Be specific.
Location of Accident
If this was a motor vehicle accident, please give street name and city or county name. If it was in a public place, please give the business name and city.
Law Enforcement Involved
If law enforcement came to the scene of the accident, please explain what branch and the city or county. (Example: Douglas Police Department, GA State Patrol, etc.)

Relative Information
Relationship to Patient*
Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Social Security Number
Sex*
- Male
- Female
Physical Address*
Full street address where relative resides.

Street Address Address Line 2 City State ZIP Code
Is your mailing address different than your physical address?*
- Yes
- No
Mailing Address
Street Address Address Line 2 City State ZIP Code
Phone Number*
Employment Status*
Employer's Name
Employer's Address
Street Address City State ZIP Code
Employer Phone Number
Retirement Date
Fill this in only if relative is retired or if is expecting to retire on a certain date.
Date Format: MM slash DD slash YYYY

Medical Information/Miscellaneous