Your medical facility must know your health information and medical history prior to your procedure. Filling out the online form is easy, secure, and essential for you to receive the best care possible.

It's a simple process…

Please be forthcoming with your responses. All of your medical information is confidential.

  • The time it takes to complete the form is dependent on your personal medical history. Typically, a person who is healthy and not taking many medications should expect to spend 15 minutes completing the form. Someone with a more complicated medical history or list of medications will take longer.
  • Upon receipt of your information, a staff member or nurse may call you for further clarification if necessary.

NOTE – You do not have to fill out a form again if you are returning to the same medical facility and have already completed this online form prior to a previous visit. A nurse or staff member will call you to discuss any changes in your medical history since your last visit.

What will I need?

Before you begin the online admissions form, please make sure that you have the following information available, as it may be needed to complete your form:

  • Prescription medicationsnames and dosage of each one you take.
  • Over-the-counter medicationnames and dosage of each one you take regularly.
  • Vitamin and herbal medications - names and dosage of any that you take.
  • Allergies/Sensitivities you have, and the allergic reaction(s) they cause.
  • Previous surgeries, and the year they were performed.
  • Medical Insuranceinsurance company, policy number, ID number, etc.

NOTE:Microsoft Internet Explorer Version 11 is not supported and it may cause the Simple Admit application to misbehave. Simple Admit recommends using Mozilla Firefox (download a free version of Firefox here), as well as Google Chrome, Safari (partially supported), or Internet Explorer Versions 9 through Version 10.

For new patients or if you wish to start a new form, please enter the password that was provided to you by your medical facility:
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1.9.2014.509 (05.09.2014)