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Home > Our Services > Patient and Visitor Guide > Preparing for Your Visit > Pre-Registration Form

Online Pre-Registration Form - Nationwide Children's Hospital

Pre-Registration Form For Nationwide Children's Hospital

Please complete the form below. All fields that are required are marked with an asterisk(*).

PATIENT INFORMATION

Has this child been admitted to Nationwide Children's Hospital before?

Yes No Not Sure

Child's Name*:

first*

middle

last*

Are there other names the child may have been registered under?

Yes No
If yes, please list:

Primary Language*

Birthdate*

mm/dd/yyyy

Address*

street*

city*

zip code*

County*

Social Security No.

Phone*

Religious Preference

Sex*

Female Male

Race*

PHYSICIAN INFORMATION

Provide information on the Attending physician. This is the specialist at Nationwide Children's Hospital who will be performing the procedure.

Name*

Phone

Provide information on the Referring physician. This is the physician who recommended that you see the specialist at Nationwide Children's Hospital.

Name*

Phone

Address

street

city

zip code

Provide information on your Primary Care Pediatrician. This is the physician your child sees for routine exams, immunizations, check-ups, etc.

Check here if your Primary Care Pediatrician is the same as the Referring Physician; otherwise, complete the information below.

Name*

Enter "None" if you do not have a Primary Care Pediatrician

Phone

Address

street

city

zip code

APPOINTMENT INFORMATION

Type of Appointment*

Inpatient
Outpatient (Surgery Center or Main Operating Room/Main OR)
23-hour observation

Chief complaint*

Does your child have any known allergies (including reactions to medication,
to food, or to other allergens)?* Yes No

If yes, please list:

INSURANCE INFORMATION

Payment Type*

Insurance/Medicaid Self Pay

PARENT/GUARDIAN INFORMATION

Relationship to Child*

Mother Father Legal Guardian

Mother's Name*
Check here if mother's address is the same as the patient's address; otherwise, complete the information below.
Mother's Address*	street*
	city*	zip code*
County*

Mother's Phone*	--

Mother's Email*	Email address will be used for future contact by Nationwide Children's Hospital only. If you have no email address, enter "n/a" in the field above.

Mother's Social Security No.*	--

Mother's Birthdate*	mm/dd/yyyy

Mother's Occupation

Mother's Employer*

Employer's Address	street
	city	zip code

Employer's Phone	--

Father's Name*
Check here if father's address is the same as the patient's address; otherwise, complete the information below.
Father's Address	street
	city	zip code
County

Father's Phone	--

Father's Email

Father's Social Security No.	--

Father's Birthdate	mm/dd/yyyy

Father's Occupation

Father's Employer

Employer's Address	street
	city	zip code

Employer's Phone	--

Father's Name*
Check here if father's address is the same as the patient's address; otherwise, complete the information below.
Father's Address*	street*
	city*	zip code*
County*

Father's Phone*	--

Father's Email*	Email address will be used for future contact by Nationwide Children's Hospital only. If you have no email address, enter "n/a" in the field above.

Father's Social Security No.*	--

Father's Birthdate*	mm/dd/yyyy

Father's Occupation

Father's Employer*

Employer's Address	street
	city	zip code

Employer's Phone	--

Mother's Name*
Check here if mother's address is the same as the patient's address; otherwise, complete the information below.
Mother's Address	street
	city	zip code
County

Mother's Phone	--

Mother's Email

Mother's Social Security No.	--

Mother's Birthdate	mm/dd/yyyy

Mother's Occupation

Mother's Employer

Employer's Address	street
	city	zip code

Employer's Phone	--

Guardian's Name*
Check here if guardian's address is the same as the child's address; otherwise, complete the information below.
Guardian's Address*	street*
	city*	zip code*
County*

Guardian's Phone*	--

Guardian's Email*	Email address will be used for future contact by Nationwide Children's Hospital only. If you have no email address, enter "n/a" in the field above.

Guardian's Social Security No.*	--

Guardian's Birthdate*	mm/dd/yyyy

Guardian's Occupation

Guardian's Employer*

Employer's Address	street
	city	zip code

Employer's Phone	--

EMERGENCY CONTACT INFORMATION

This should be someone with a different address
and phone number than the child.

Name*

Relationship to Child*

Phone*

Before clicking the submit button, please review your information. You will not have the opportunity to edit it, however you will be able to print out your completed form after submitting. If you elect to electronically submit a completed Pre-registration Form or any other form or information to Nationwide Children's 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 Nationwide Children's 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 Nationwide Children's Hospital by you through this Web site, including a completed Pre-registration Form, does not create or constitute any relationship between you and Nationwide Children's Hospital, its affiliates, or any of the physicians on its staff, to which any privilege may attach.

Nationwide Children's Hospital
700 Children's Drive Columbus, Ohio 43205 614.722.2000