Littleton Regional Hospital Pre-admission form

Our secure pre-admission form offers you the convenience of providing us with information about yourself at your leisure and in the comfort of your own home or office. In addition, it saves you time the day of your visit because Patient Access staff will not need to obtain as much information from you upon your arrival. Using the form is not only convenient it is also safe-all the information you submit is secured using Secure Socket Layer (SSL) technology.

Fields marked * are REQUIRED.

Please submit this online pre-admission form four days before a scheduled procedure or test.

Patient Information:

First Name*

Middle Initial

Last Name*

Suffix (Sr., Jr., etc)

Email Address*

Mailing Address*

City* State* Zip*

Street Address (if different from above):

City State Zip

Home Phone Number*

Date of Birth*

SexMale: | Female:

Marital Status

Race

The State of New Hampshire, through their mandate of the hospitals, requires the collection of race.

Religious Denomination

If under 18 years of age, parent information:

First Name

Last Name

Relationship

If married, Spouse information:

First Name

Last Name

Employer Name

Employer Address

Employer City State Zip

Employer Phone

Patient Employer Information:

Employment Status

If Retired, when?

Employer Name

Employer Address

Employer City State Zip

Employer Phone

Emergency Information:

Emergency Contact

Relationship to Patient

Address

City State Zip

Home Phone

Work Phone

Cell Phone

Medical Information:

Primary Care Physician

Physician Performing Procedure or Test*

Have you ever been treated at LRH?Yes: | No:

If yes, your Last Name at that time

Is this visit due to an accident?Yes: | No:

If yes, date of injury

Is this visit due to a work-related accident?Yes: | No:

If yes, Name of Employer at the time

If Yes, Name of Work Comp Insurance

Insurance Information:

Littleton Regional Hospital accepts and bills most insurance companies as a courtesy to patients. Your insurer is under contract with you and/or your employer. If your insurance carrier does not make payment, the bill may ultimately be your responsibility. Please be aware that most insurance companies require prior authorization before an elective or urgent admission.

Are you covered by medical insurance? Yes || No

If Yes, Please complete the following information:

Insurance Name

Claims Address

City State Zip

Phone Number

Policy or ID Number

Group Number

Person carrying the insurance policy:

First Name

Last Name

Relationship to Patient

Advanced Directives

In New Hampshire, you have the right to let others know your wishes regarding medical care in advance through living wills or durable power of attorney.

Do you have a living will or durable power of attorney for healthcare?

If yes, bring a copy of the document with you the day of your procedure or test unless LRH already has a copy.

Submit Form

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Littleton Regional Hospital 600 St. Johnsbury Road Littleton, NH 03561 Phone: 800-464-7731