Please submit your online pre-registration at least 48 hours in advance of check-in to ensure timely processing.
If you choose to utilize our Pre-registration Form, understand that you do so at your own choice and risk. Any information you submit via the Pre-registration Form is confidential and is only shared with third parties as outlined in our Privacy Pledge. For more information, please read our Patient Privacy Notice.
Pre-registration Disclaimer
If you elect to electronically submit a completed Pre-registration Form or any other information to Northwest Hills Surgical Hospital through this web site, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or omissions in the data you provide. You agree to release and hold Northwest Hills Surgical Hospital and its affiliates (including its directors, officers, employees, shareholders, agents and representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of any information submitted electronically by you through this web site and from any errors or omissions in the data you provide. Additionally, the provision of any information to Northwest Hills Surgical Hospital by you through this web site, including a completed Pre-registration Form, does not create or constitute any relationship between you and Northwest Hills Surgical Hospital, its affiliates, or any of the physicians on its staff, to which any privilege may attach.
CLICK ON EACH FORM. READ THE CONTENT. COMPLETE THE DATA. PRINT THE FORM. SIGN EACH FORM. BRING ALL FORMS WITH YOU TO YOUR APPOINTMENT.
Conditions of Service This form outlines the conditions of service and allows us to treat you and to bill your insurance on your behalf as a courtesy to you.
Patient Information This form ensures that we have accurate information concerning your identity and insurance information.
Medical History This form gathers information concerning your medical history so that we can provide the best clinical experience for you.
Personal Medications This form documents all of the medications you are taking, both prescription and over-the-counter, to ensure your safety.
What Is Pain? This form explains how we measure your pain level.
Pain Questionnaire This form identifies any pain you may be experiencing and assists us in treating your pain appropriately.
Communication Authorization This forms lets you identify with whom we may communicate regarding your condition and plan of care. We will not release information other than to those specified on this form.
Privacy Acknowledgement This form verifies that you have received documentation concerning our privacy practices. Please click on the link below "Patient Privacy Notice" to read and/or print this document.
Post-op Call Information This form gives us permission to call you after your surgery to ensure your health and well being. Please identify the most appropriate telephone number to use and any restrictions you may have (i.e., please don't call after 9:00 pm).
For your convenience Northwest Hills Surgical Hospital is now offering online pre-registration for your surgery. Registration is designed to be quick and easy and completing the form should take you 10-15 minutes. Please have your insurance information handy.