Patient Pre-registration

Patient Pre-registration


If you are scheduled for a procedure at a Roper St. Francis facility, you will need to pre-register for it in advance. Our Online Pre-Registration process makes it easy! Simply fill in all the applicable fields. It's that simple!

If at anytime you have questions while registering online, you may call (843) 402-5100, (Mon. - Fri., 8 a.m. - 5 p.m.) for assistance.


Fields marked with an asterisk * are required fields

Patient Type

Select a Patient Type:

Facility

Facility:
A-Roper Hospital, Roper Berkeley ...

Patient Information

Patients First Name: *
Patients Middle Initial:
Patients Last Name: *
Patients SSN: * 
Patients Date of Birth(MM/DD/YYYY): * 
Patients Marital Status: *
Spouse First Name:
Spouse Middle Initial:
Spouse Last Name:
Patients Race:
Patients Ethnicity: *
Patients Email Address:
Patients Home Phone: *
Patients Cell Phone:
Patients Denomination:
Select your Religion
Place name on Pastoral List:

Patient's Residential Address

Patients Residential Address: *

Patients City: *
Patients State: *  
Patients Zip Code: *  

Patient's Mailing Address if different than Residential Address

Patients Mailing Address:

Patients City:
Patients State:
Patients Zip Code:

Maternity Patient

Date of last Menstrual Cycle(MM/DD/YYYY): *
Expected Due Date(MM/DD/YYYY): *
Obstetrician Name:
Patients OB Doctor:
Child covered under Mother/Father's insurance:

 
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