To ensure proper processing, please submit this form at least two business days (48 hours) prior to your scheduled procedure or test.  

* Indicates required information
Have You been a Patient At Exempla Healthcare in the past? 
 * 
Patient Information 
Last Name * 
First Name * 
Middle Name or Initial  
Date of Birth * 
Gender * 
Mailing Address * 
City * 
State * 
Zip * 
Phone Number * 
Secondary Phone Number 
Marital Status * 
Patient's Social Security Number 
Your Email Address (leave blank if you do not wish to receive email) 
Email Address 
Patient Employer Name 
Employer Address 
Employer Phone Number 
Emergency Contact  
Last Name * 
First Name * 
Phone Number * 
Secondary Phone Number 
Relationship to Patient * 
Insurance Information - Please bring your insurance card. 
Name of Insurance Company 
Claims Mailing Address: 
City 
State 
Zip Code 
Customer Service Phone Number 
Policy/Subscriber ID Number 
Group # 
Is insurance through an employer other than Patient's current employer? * 

Name of Person Carrying Insurance 
Policy Holder Employer Group Name 
Secondary Insurance information OR maternity patients whose baby will be covered by insurance other than mother.  
Name of Insurance Company 
Claims Mailing Address: Street 
City 
State 
Zip Code 
Customer Service Phone Number 
Policy/Subscriber ID Number 
Relationship to Patient 
Policy Holder Employer Group Name 
Group # 
If accident related, please provide Date of Injury  Calendar (mm/dd/yyyy)
Type of accident: work, auto, other 
Procedure Information 
Date of Test/Procedure  Calendar (mm/dd/yyyy)
Type of Test or Procedure 
Doctor Ordering Test or Procedure 
Primary Care Physician 
Diagnosis and/or Reason for Visit 
 
Maternity Patients Only 
Due Date (for OB patients) 
OB Doctor (for OB patients)