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NEWS & EVENTS
- JRMC U
SPECIALTIES
PATIENT CARE
RESOURCES
GIVING

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Pre-Register Family BirthPlace

Jamestown Regional Medical Center
Pre-Register Family BirthPlace

- Step 1 of 4

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth *

Social Security

Phone *

Email *

Preferred Method of Contact *

PHONE
EMAIL

Martial Status *

If Other *

Race *

If Other *

Religious Preference

Allow Clergy Visit

YES
NO

Appointment Type *

MATERNITY

Anticipated Due Date *

Primary Care Provider *

Employer *

Employment Status *

If Other *

Emergency Contact

Name *

First

Last

Relation *

If Other *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Insurance information

Healthcare Bills Paid Using *

If Other *

Additional Insurance *

BC/BS of *

If Other *

Medicaid of *

If Other *

Would you like a patient financial advocate to contact you regarding what insurance options are available? *

YES
NO

Policy Holder's Name *

First

Last

This Policy Is Through The Following Employer:

Policy Number *

Policy Phone Number *

Effective Date *

Policy Address *

Address Line 1

Address Line 2

City

State

Zip Code

More Than One Policy Holder? *

YES
NO

Additional Policy Holder's Name *

First

Last

This Policy Is Through The Following Employer:

Policy Number *

Policy Phone Number *

Effective Date *

Policy Address *

Address Line 1

Address Line 2

City

State

Zip Code

Reason for Medicare Benefit *

DISABILITY

Medicare Coverage *

PART A ONLY (HOSPITAL)
PART B ONLY (MEDICAL)
BOTH

Newborn Coverage *

SAME AS MOTHER
DIFFERENT THAN MOTHER

Newborn Insurance *

If Other *

Additional Insurance *

BC/BS of *

If Other *

Medicaid of *

If Other *

Would you like a patient financial advocate to contact you regarding what insurance options are available? *

YES
NO

Reason for Medicare Benefit *

DISABILITY

Medicare Coverage *

PART A ONLY (HOSPITAL)
PART B ONLY (MEDICAL)
BOTH

Policy Holder's Name *

First

Last

Policy Number *

Policy Phone Number *

Effective Date *

Policy Address *

Address Line 1

Address Line 2

City

State

Zip Code

More Than One Policy Holder? *

YES
NO

Additional Policy Holder's Name *

First

Last

Policy Number *

Policy Phone Number *

Effective Date *

Policy Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mother Under 18? *

YES
NO

Guarantor Name *

First

Last

Relation *

If Other *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Social Security

Do you plan to schedule a tubal ligation with the delivery? *

YES
NO

< Back to Online Scheduling

Online Scheduling

Welcome to online scheduling at Jamestown Regional Medical Center.

New and current patients can schedule an appointment in just a few clicks.

If you’re experiencing an emergency, call 911.

Ear, Nose & Throat Gynecology & Obstetrics Orthopedics Podiatry / Foot & Ankle Urology

Orthopedics

Please select a location for your appointment.

Jamestown Carrington

Podiatry / Foot & Ankle

Please select a location for your appointment.

Jamestown Carrington

JRMC Ear, Nose & Throat

JRMC Gynecology & Obstetrics

JRMC Orthopedics: Jamestown

JRMC Orthopedics: Carrington

JRMC Podiatry / Foot & Ankle: Jamestown

JRMC Podiatry / Foot & Ankle: Carrington

JRMC Urology

Don’t see the service you are looking for? Click here or call (701) 952-1050.

Online scheduling functionality is powered by Sanford Health. The appointment you are making is with a Jamestown Regional Medical Center provider.

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Get In Touch

We would love the opportunity to help.

2422 20th Street SW Jamestown, ND 58401
(800) 281-8888
info@jrmcnd.com

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