Bon Secours Richmond Hospital Registration -

Please answer all questions and hit the submit button at the end. This will automatically register you for your hospital stay and ensure a smooth admission.

Please do not complete if your hospital stay is within the next 48 hours. You will be registered when you arrive at the hospital.

*Required Information. (Please enter all required information in order to avoid having to re-key each field.)

* First Name:
* Middle Name:
(Enter "None" if no middle name)
* Last Name:
* Street Address:
* City:
* State/Province:
* Zip Code:
* Arrival Date
(Due date if pregnant):		  (mm/dd/yyyy)
Pediatrician for baby (if decided):
Baby Club Registration: Please register me for the Bon Secours Baby Club and my discounts, including a $100 discount on my portion of my hospital bill.
* Admitting Physician,
OB-Gyn, or CNM
Full Name:
(Enter “NA” if not applicable)
* Primary Care Physician Name:
(Enter “None” if no PCP)
* Home Phone:  (000) 000-0000
*E-mail:
(Please use default if you do not have an e-mail address)
*Choose your hospital:
*Marital Status:
Maiden Name:
*Social Security Number: (000-00-0000)
*Birth Date: (mm/dd/yyyy)
*Religious Preference:
*Race:
Primary Insurance Information
(Complete this section on whomever is the carrier of the insurance.)
*Subscriber's Full Name:


(enter “Same” if same as patient)

*Subscriber's Social Security Number:

(000-00-0000)
(enter “Same” if same as patient,
if unknown, please enter 999-99-9999)

*Subscriber's Date of Birth:

(mm/dd/yyyy)
(enter “Same” if same as patient,
if unknown, please enter 01/01/1900)

*Relationship to Patient:

*Insurance Company Name:
*Insurance Co. Claims Address:


(Found on back of card)
Insurance Company Phone:
*Subscriber’s I.D.#:


(Found on card)

*Group #:


(Enter “None” if no group number)

*Subcriber’s Employment status:
*Employer / Group Name:
Secondary Insurance Information
(If applicable – not all patients have a secondary insurance.)
Subscriber’s Full Name:
Subscriber’s Social Security Number:

(000-00-0000)
(enter “Same” if same as patient,
if unknown, please enter 999-99-9999)

Subscriber's Date of Birth:

(mm/dd/yyyy)
(enter “Same” if same as patient,
if unknown, please enter 01/01/1900)
Relationship to Patient:

Insurance Company Name:
Insurance Co. Claims Address:


(Found on back of card)
Subscriber’s I.D.#:


(Found on card)

Group #:


(Enter “None” if no group number)

 Subcriber’s Employment status:
Employer / Group Name:
Emergency Contact Information
First Name:
Middle Name:
Last Name:
Street Address:
City:
State/Province:
Zip Code:
Home Phone:

 (000) 000-0000
Work or Cellular Phone:

 (000) 000-0000
Relationship to Patient: