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Patient Pre-Registration Form |
| 1. Please open our eMail by clicking
here.
An eMail will open for you with our address already filled in.
2. Then copy and paste the form in the yellow
area below and add in your information to
the email and click send when you are finished. |
| You should submit this email to set-up and confirm
your appointment at the Center. If you have questions about registering online,
contact us at (360) 547-1100. The information you provide will be handled
according to our Privacy Policy.
We will call you within one business day after we receive your email
Pre-Registration Form. |
Desired Arrival Date:
_______________
Type of Service __Rheumatoid Arthritis __Osteoarthritis__ Gout__ Other
First Name: __________________ Initial _______
Last Name: ____________________
Address: _____________________________
City:
________________________ State ______ Zip___________
Home Phone: _________________ Work Phone
__________________
Email:
______________________
Date of Birth: _____________ Social Security No: ________________
Gender __________________ Marital Status:
___________________
Height _______Feet _______In.
Weight _________Lbs.
Employment Status _____Full Time _____Part Time ________ Retired
Employer: _______________________________
Address:
_____________________________
City:
________________________ State ______ Zip___________
Employer Phone: __________________
Nearest Relative -
First Name __________________ Initial _______
Last Name ___________________________
Address: _____________________________
City:
________________________ State ______ Zip___________
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|
This information will only be used by The
Center for Advanced Medicine. |
|
US Phone: 1-360-547-1100 Mexican
Phone: 011-5281-8303-0788 |
