Faulkner Hospital - Online registration

Online Registration Form at Faulkner Hospital

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.

Patient Information
• *First Name:
• MI:
• *Last Name:
• *Date of Birth: (format "MM/DD/YYYY")
• *Address:
• *City:
• *State:
• *Zip:
• *Phone:
• Work/alternate phone:
• Email:
• Other legal names:
• *Marital Status:
• Religious Preference:
• *Employment Status:
• Occupation:
• * Gender:	Male Female
Employer Information
• Company:
• Phone:
Emergency Contact Information
• *Full Name:
• Relationship to patient:
• *Phone:
• Work/alternate phone:
Primary Insurance
• *Insurance Company:
• *Phone:
This address and phone number can be found on your insurance card.
• Address:
• City:
• State:
• Zip:
• *Policy #:
• Group Number:
Secondary Insurance (if applicable)
• Insurer:
• Phone:
• Address:
• City:
• State:
• Zip:
• Policy #:
• Group Number:

Appointment Information

• *Date of service (format "MM/DD/YYYY"):

• *What department is your appointment in?:

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:

• If you have selected other please explain:

• *Ethnicity:

• If you have selected other please explain:

• *Primary Language Spoken:

• If you have selected other please explain:

• *What language do you prefer to discussHealth Concerns?

• *What language do you prefer to read Health Materials?

• *Highest Level of Education:

• If you have selected other please explain:

• *In what Country did you reach your highest Level of Education:

• 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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