OB Pre-Registration

https://apiprod.commonspirit.org/api/v1/validation/token

https://apiprod.commonspirit.org/api/v1/patient-regis/appointment/

https://apiprod.commonspirit.org/api/v1/patient-regis/patient/

https://apiprod.commonspirit.org/api/v1/patient-regis/insurance/

https://apiprod.commonspirit.org/api/v1/patient-regis/condition/search?outreachKey=

https://apiprod.commonspirit.org/api/v1/patient-regis/medicationRequest/search?outreachKey=

https://apiprod.commonspirit.org/api/v1/patient-regis/allergy/search?outreachKey=

https://apiprod.commonspirit.org/api/v1/patient-regis/pams/

https://apiprod.commonspirit.org/api/v1/patient-regis/vRegStatus

https://apiprod.commonspirit.org/api/v1/patient-regis/questionnaireResponse/

https://apiprod.commonspirit.org/api/v1/patient-regis/questionnaire/

https://apiprod.commonspirit.org/api/v1/patient-regis/dictionary/

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PRE-ADMITTING FORM

CONFIDENTIAL
Please complete this preregistration form and return it to the Admitting Department at Community Hospital of San Bernardino.
When you arrive at the hospital, your paperwork will be complete and you can concentrate your efforts on a safe and healthy delivery. All you need to do at the time of admission or pre-admission is show your identification and medical insurance cards.

Please complete this pre-registration form within 90 days of your estimated delivery date.

This will allow us to complete your paperwork before your arrival so you can concentrate your efforts on a healthy delivery. All you need to do at the time of admission or pre-admission is show your identification and medical insurance cards.

Have you previously been treated at Community Hospital of San Bernardino? *

Yes

PATIENT

Due Date *

Last Name *

First Name *

Middle Name

Birth Name

Home Address / Apartment / Space Number *

City *

ZIP Code *

Telephone / Cell Number *

Birth Date *

Marital Status *

Religion *

E-Mail Address *

Birth Place *

Primary Language *

Social Security Number *

Driver License Number

EMPLOYMENT

Employer *

Ocupation *

Business / Employer Address

City

ZIP Code

Telephone

MATERNITY

Type of Admission

Primary Care Physician Name

Address

Telephone Number

SPOUSE/PARENT/COMPANION

Last Name (Spouse/Parent/Companion) *

First Name *

Middle Name

Social Security Number

Address *

City *

ZIP Code *

Telephone *

Birth Date *

Employer *

City

Telephone

Last Name

First Name

Middle Name

Relation to Patient

Address

City

ZIP Code

Telephone

INSURANCE

Primary Insurance *

Policy Holder Name *

Relation to Patient *

Policy Holder Address

City

ZIP Code

Telephone

Social Security Number *

Group Name / ID Number *

Secondary Insurance

Policy Holder Name

Relation to Patient

Policy Holder Address

City

ZIP Code

Telephone

Social Security #

Group Name / ID Number