Please click visitor information to the right for directions and any other general hospital information.

Online Pre-registration is  available for appointments 24 or more hours from now. This is to ensure there is adequate time to process the registration and avoid patient delays or inconvenience on the day of your visit.

If you have questions/issues regarding the use of our online form or for appointments that are scheduled for less than 24 hours from now:

To register for Breast Imaging Services (breast MRI, bone density, mammography),call 617-983-7068.

Their hours are Monday-Thursday 7 am - 8 pm, Friday 7 am - 3:30 pm and
Saturday 8 am - 3 pm

To register for All Other services please call 617-983-7010.

Their hours are Monday-Friday 6 am - 8pm.

This website is secured by 128-bit SSL encription for your protection.

* = Required Field

• * I have read and agree to the HIPAA Guidelines (Health Insurance Portability Accountability Act).
  
  
• * I am pre-registering more than 24 hours before the appointment.
  
  
• I give permission to Faulkner Hospital to contact me regarding this
  pre-registration.

Please have your insurance card available in order to complete the form.

• * First Name: MI:
• * Last Name:
• * Date of Birth: (format "MM/DD/YYYY")
• *Address:
• * City:
• * State: Choose a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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 Washington DC West Virginia Wisconsin Wyoming *Zip:
• * Phone:
• Work/alternate phone:
• Email:
• * Gender: Male Female
• Other legal names:
• *Marital Status: Choose one Married Single Widowed Separated Divorced
• Religious Preference:
• *Employment Status: Choose one Employed Unemployed Retired
• Occupation:

• Company:
• Phone:

• * Full Name:
• Relationship to patient:
• * Phone:
• Work/alternate phone:

• * Insurance Company:
• * Phone:
  
  This address and phone number can be found on your insurance card.
  
  
• Address:
• City:
• State: Choose a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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 Washington DC West Virginia Wisconsin Wyoming Zip:
• * Policy #:
• Group Number:

• Insurer:
• Phone:
• Address:
• City:
• State: Choose a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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 Washington DC West Virginia Wisconsin Wyoming Zip:
• Policy #:
• Group Number:
  

Appointment Information

• * Date of service : (format "MM/DD/YYYY")
  
• * What department is your appointment in?: Choose one Audiology Cardiac Rehabilitation Colonoscopy Dietary/Nutrition Echocardiology EKG Endoscopy ERCP Event Monitor Holter Monitor Lab* (Standing Orders Only) Pain Clinic Center for Pre-Operative Evaluation Radiology-CT Scan Radiology-Diagnostic X-ray Radiology-MRI Radiology-Ultrasound Sagoff-Mammography Sagoff-Bone Density Sagoff-Breast MRI Sigmoidoscopy Sleep Study Stress Test Ultrasound Vascular Lab
  
  Note- We are not able to Pre-Register Lab visits at this time unless you have a Standing Order on file at this Hospital.
  
  
• Reason for Appointment:
  
• * What Physician referred you for this Appointment?:
  
  
• Primary Care Physician:
  
  
• * Have you been a patient at Faulkner Hospital before? Yes No
  
  

Patient Information (Required by the State of MA)

To choose your selection please use the drop boxes below. If your choice is other, please use the box at the end of the section to explain your answers.

• * Race: Choose one American Indian/Alaska Native Asian Black Hispanic Latino Native Spanish White/Caucasian Other (Please Specify) Declined
  If you have selected other please explain:
  
  
• * Ethnicity: Choose one African American African American Asian Asian Indian Brazilian Cambodian Caribbean Island Central American (Other) Chinese Columbian Cuban Cape Verdean Dominican Eastern European European Filipino Guatemalan Haitian Hondurian Japanese Korean Laotian Mexican, American Chicano Middle East/ North African Portugese Puerto Rican Russian Salvadoran South American (Other) Vietnamese Other (Please Specify) Declined
  If you have selected other please explain:
  
  
• * Primary Language Spoken: Choose one African Arabic Chinese Cape Verdean Creole English French German Greek Haitian Creole Hebrew Hindi Italian Japanese Korean Persian Polish Portugese Russian Sign Language Spanish Tagalog Urdu Vietnamese Other (Please Specify) Declined
  If you have selected other please explain:
  
  
• * What language do you prefer to discuss Health Concerns?
• * What language do you prefer to read Health Materials?
  
  
• * Highest Level of Education : Choose one Graduated- High School Graduated from College Graduated/Grad School Graduated/PostGrad School Some High School 8th Grade or Less I Did Not Attend School Obtained a GED Some College Some Vocational Program Some Technical Program Other (Please Specify)
  If you have selected other please explain:
  
  
• * In what Country did you reach your highest Level of Education ? Choose one Not in US In The US Declined
  
  
• Do you have a Health Care Proxy: Yes No
• If yes, Does Faulkner Hospital have a copy? Yes No
• If you have a Heath Care Proxy but Faulkner Hospital does not have a copy please complete:
  
  Health Care Proxy Name:
  
  Health Care Proxy Phone:
  

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