Trinity Regional Health System
Pre-Admission Form

Thank you for choosing Trinity. To assist in making your admission process easier, please complete this form within 48 hours of receiving it. When finished, you may submit it electronically or print and mail it. If you have questions regarding this process, call (309) 779-5960.

What you will need:
- insurance card(s) and information about the subscriber(s)
- contact information for your spouse and/or alternate contact
- information about past surgeries and any medications you are taking
- about 20 minutes to complete this form.

* required info
I will be admitted to: Trinity West (Rock Island)
Trinity 7th Street (Moline)
Trinity Terrace Park (Bettendorf)
Patient Information
Patient's last name: *
First name: *
Middle initial:
Date of birth: * Month: Date:Year:
Please format date of birth as 01-01-1901.
Social Security number: * --
Marital status: * Married
Single
Divorced
Widowed
Separated
Address: *
City: *
State: *
Zip: *
Home phone: () -
Work phone: () -
Cell phone: () -
If any additional information is needed, which number(s) would you like us to call? Daytime
Evening
Cell
Religion:
Church:
City:
Patient's Employment Information
Employer name:
Employer address:
City:
State:
Zip:
Status of employment: Full time
Part time
Retired
Active military
If retired, please give retirement date:
Additional Patient Information
Surgeon: First: Last:
Primary care physician: First: Last:
Cardiologist: First: Last:
Other physician: First: Last:
Does patient have an allergy to latex? Yes
No
Does patient have a Living Will? Yes
No
Does patient have a Health-care Power of Attorney? Yes
No
Would patient like his/her church notified of procedure? Yes
No
Patient's Spouse's Information
Spouse's last name:
First name:
Middle initial:
Date of birth:
Employer name:
Employer address:
City:
State:
Zip:
Status of employment: Full time
Part time
Retired
Active military
If spouse is retired, please give retirement date:
Alternate Contact Information
Last name:
First name:
Relationship to patient:
Address:
City:
State:
Zip:
Home phone: () -
Alternate phone: () -
Insurance Information
Plan 1:
Insurance name:
Policy number:
Group number:
Insurance company address:
City:
State:
Zip:
Phone number: () -
Subscriber's name:
Note: If subscriber is same as patient, enter "Same as patient" and skip down to question regarding insurance pre-certification.
Subscriber's date of birth:
Employer's name:
Employer's address:
City:
State:
Zip:
Employer phone: () -
Status of employment: Full time
Part time
Retired
Active military
If subscriber retired, please give retirement date:
Subscriber's relationship to patient:
Pre-certification (pre-approval) required? Yes
No
Unknown
Plan 2:
Insurance name:
Policy number:
Group number:
Insurance company address:
City:
State:
Zip:
Phone number: () -
Subscriber's name:
Note: If subscriber is same as patient, enter "Same as patient" and skip down to question regarding insurance pre-certification.
Date of birth:
Subscriber's employer's name:
Employer's address:
City:
State:
Zip:
Employer phone: () -
Status of employment: Full time
Part time
Retired
Active military
If subscriber retired, please give retirement date:
Subscriber's relationship to patient:
Pre-certification (pre-approval) required? Yes
No
Unknown
Medical Questionnaire
Select all of the following medical conditions that the patient is currently being treated for or has been treated for in the past. Diabetes
Hypertension/high blood pressure
Heart problems
Seizures/epilepsy
Lung problems
Stroke or TIA
Kidney problems
Cancer
Blood clots
Ulcers
Thyroid problems
Arthritis
Anemia
Hepatitis
History of depression, anxiety or panic attacks
Has patient had an EKG within the last six months? Yes
No
If yes, where?
History of past surgeries/hospitalizations and the year in which they took place.
Please list medications patient is taking, along with dosages and how many times a day taken.
You have completed the pre-registration form. Please review information for accuracy.

You may send your information by printing it and mailing it to:
Trinity Medical Center
2701 17th Street
Rock Island, IL 61201
Att: Pre-Surgical Testing 7th Street Campus



Or, you may click Send to submit your information electronically. Learn about the secure handling of your personal information.