Silver Cross Hospital

The way you should be treated.™

Request an Appointment

Patient Name
Invalid Input

First Name (*)

Invalid Input
Last Name (*)

Invalid Input
Social Security Number (*)

Please enter your social security number

Contact Name (if different than patient name)

First Name

Invalid Input
Last Name

Invalid Input
Primary Phone Number (*)

Invalid Input
Best time to call (*)





Please let us know the best time to call you
Have you been a patient here before?

Invalid Input


Pre Registration



Pre-Registration In order to expedite the registration process on the day of your appointment, please complete the registration information below. Required fields are marked with an asterisk ('*'). Or you may contact our Pre-Registration service at 815-740-7086.
First Name (*)

Invalid Input
Middle name

Invalid Input
Last Name (*)

Invalid Input
Suffix

Invalid Input
Maiden Name

Invalid Input
Sex (*)

Invalid Input
Address (Line 1)

Invalid Input
Address (Line 2)

Invalid Input
City (*)

Invalid Input
State (*)

Invalid Input
Zipcode (*)

Invalid Input
Home Phone (*)

Please enter your primary phone number
Other Phone

Invalid Input
Marital Status

Invalid Input
Race (*)

Invalid Input
Date of Birth (*)

Invalid Input

Guarantor



Is this patient the guarantor?

Invalid Input
If not, shall we use this same address for the guarantor?

Invalid Input
Shall we use this same address for your emergency contact?

Invalid Input

Employer


Employment Status

Invalid Input
Name of Employer

Invalid Input
Address (line 1)

Invalid Input
Address (line 2)

Invalid Input
City

Invalid Input
State

Invalid Input
Zip Code

Invalid Input
Phone Number

Invalid Input


Please complete the following form.

Next of Kin



This person must live at a different address from the patient's address.

First name

Invalid Input
Last Name

Invalid Input
Address (Line 1)

Invalid Input
Address (Line 2)

Invalid Input
City

Invalid Input
State

Invalid Input
Zip Code

Invalid Input
Home Phone

Invalid Input
Work Phone

Invalid Input
Relation to Patient

Invalid Input

Emergency Contact


Shall we notify this person in case of emergency?

Invalid Input
Shall we use this same address for your emergency contact?

Invalid Input


Person to Contact in Case of Emergency



First name

Invalid Input
Last Name

Invalid Input
Address (line 1)

Invalid Input
Address (line 2)

Invalid Input
City

Invalid Input
State

Invalid Input
Zip Code

Invalid Input
Home Phone

Please enter a valid phone number
Work Phone

please enter a valid phone number
Relation to Patient

Invalid Input


Guarantor Information


First name

Invalid Input
Last Name

Invalid Input
Address (line 1)

Invalid Input
Address (line 2)

Invalid Input
City

Invalid Input
State

Invalid Input
Zip Code

Invalid Input
Home Phone

Please enter a valid phone number
Work Phone

please enter a valid phone number
Social Security #

Invalid Input
Employment Status

Invalid Input
Name of Employer

Invalid Input
Address (line 1)

Invalid Input
Address (line 2)

Invalid Input
City

Invalid Input
State

Invalid Input
Zip Code

Invalid Input
Employer Phone

Invalid Input


Primary Insurance


Name of Insurance Company

Invalid Input
Insurance Policy Number

Invalid Input
Name of Policy Holder

Invalid Input
Insurance Group Number

Invalid Input

Secondary Insurance


Name of Insurance Company

Invalid Input
Insurance Policy Number

Invalid Input
Name of Policy Holder

Invalid Input
Insurance Group Number

Invalid Input


Located at 1900 Silver Cross Blvd., New Lenox, IL 60451   Main Phone (815) 300-1100

© Copyright 2017  Silver Cross Hospital. All Rights Reserved.

 

  

Physicians on Silver Cross Hospital’s Medical Staff have expertise in their areas of practice to meet the needs of patients seeking their care.  These physicians are independent practitioners on the Medical Staff and are not the agents or employees of Silver Cross Hospital. They treat patients based upon their independent medical judgment and they bill patients separately for their services.