Silver Cross Hospital

The way you should be treated.™

Request an Appointment

Patient Name


First Name(*)

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Last Name(*)

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Contact Name (if different than patient name)


First Name

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Last Name

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Primary Phone Number(*)

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Best time to call(*)





Please let us know the best time to call you

Have you been a patient here before?

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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(*)

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Middle name

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Last Name(*)

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Suffix

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Maiden Name

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Sex(*)

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Address (Line 1)

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Address (Line 2)

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City(*)

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State(*)

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Zipcode(*)

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Home Phone(*)

Please enter your primary phone number

Other Phone

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Marital Status

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Race(*)

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Employer




Employment Status

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Name of Employer

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Address (line 1)

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Address (line 2)

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City

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State

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Zip Code

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Phone Number

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Please complete the following form.



Next of Kin





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


First name

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Last Name

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Address (Line 1)

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Address (Line 2)

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City

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State

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Zip Code

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Home Phone

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Work Phone

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Relation to Patient

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Emergency Contact




Shall we notify this person in case of emergency?

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Shall we use this same address for your emergency contact?

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Person to Contact in Case of Emergency




First name

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Last Name

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Address (line 1)

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Address (line 2)

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City

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State

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Zip Code

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Home Phone

Please enter a valid phone number

Work Phone

please enter a valid phone number





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.