Patient Pre-registration

Welcome to Nashoba Valley Medical Center's online pre-registration.

By successfully pre-registering online, you will be able to go directly to the department where your test is being performed.

This pre-registration service is currently limited to certain services/testing departments.

Your appointment must already be scheduled. The date of your appointment should be between 2 - 30 days from the date you submit this form.

Patient Information
MM/DD/YY Test should be at least two days from now.
What type of test do you have an appointment for?
  • AUDIOLOGY
  • BONE DENSITY
  • CARDIAC REHAB
  • CARDIOLOGY
  • CT SCAN
  • ENDOSCOPY
  • MAMMOGRAPHY
  • MRI
  • ONCOLOGY
  • OCCUPATIONAL THERAPY
  • PAIN MANAGEMENT
  • PHYSICAL THERAPY
  • RESPIRATORY THERAPY
  • SLEEP LAB
  • SPEECH THERAPY
  • ULTRASOUND
What Doctor ordered this test? Last name, first name
Last name, First name
Last name, First name
Full Street Address or P.O. Box including Apt # if applicable
Five digit zip code
Area Code and 7 Digit Number
MM/DD/YY
  • Single
  • Married
  • Divorced
  • Separated
  • Widowed
  • Black
  • White
  • Asian
  • Native American
  • Hispanic
Last 4 digits
Religious Affiliation
Please include any food or drug allergies or type NONE
Are you allergic to Latex?
  • Yes
  • No
  • Student
  • Self Employed
  • Retired
Please answer if employed or a student. Must be completed if the source of payment is Worker's Comp
Five Digit Zip Code
Must be filled in if you have Medicare
Person to Notify Information
Five digit zip code
Cell phone or Business Phone Please indicate which. Or type NONE
Guarantor Information
To be filled out only if patient is a minor
Five digit zip code
Area Code and 7 Digit Number
Last 4 digits
Five digit zip code
Area Code and 7 Digit Number
  
Insurance Information
  • Health Insurance
  • Worker's Comp
  • Auto Insurance
  • Self Pay
Has your insurance information changed since the last time you pre-registered online? If no, please skip to contact information.
Enter the name of your health insurance as it appears on your card here. If you have no insurance, enter none here and on the other required fields.
Name on the card or person who is paying for insurance through their employer
Usually located on the back of the card. Mail claims to:
If you have more than one insurance, please list your second insurance here
Name on the card or person who is paying for insurance through their employer
Usually located on the back of the card. Mail claims to:
If you have any additional insurances, please give us the name of the insurance, policy #, policy holder and address
Nashoba Valley Medical Center has permission to reach me if the information here does not match my records. I understand that if I do not give NVMC permission to reach me, my pre-registration may need to be repeated at the hospital. I would like to be reached by:
  • Phone
  • Email
  • Not at All
If you have requested that we contact you by email in the question above, enter your email address here

Connect with Steward

Visit Our Twitter Feed Visit Our Facebook Page Visit Our YouTube Channel Email This Page Share This Page Print This Page

Subscribe to Believe

Our electronic health news
Steward DoctorFinder The Joint Commission National Quality Approval Seal

Interpreter Services
Copyright © 2014 Steward Health Care
Connect Healthcare Panacea CMS Solutions