Forms - East Jefferson General Hospital - The Premier Hospital in Metairie, LA

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Lorem ipsum dolor Authorization For Treatment

Fields marked with an asterisk(*) are required.
General Information
- Employee's Name*
- Injury Date*
  MM slash DD slash YYYY
Injury Time*

: Hours

Minutes

AM/PM
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Employer Information
Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
- Phone*
- Person Authorizing Treatment*
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Reason(s) For Visit (Please select all that apply.)
- Physical Exam Needed?
  - Yes
  - No
- Physical Exam Type
- Urine Drug Test
  - Federal (DOT/CDL)
  - Non Federal (State)
- Reason for test
- Alcohol Test
  - Screen
  - Evidential Breath
  - Blood
- Injury
  - Workers' Comp
  - General Liability
Additional Testing/Comments:
Please note: Upon form completion, EJGH will forward your employee's information to Pelican State Occupational Medicine. They will be providing any applicable evaluations, treatments, and return to work status letters.
Pelican State Urgent Care
1525 Dickory Ave., Harahan, LA 70123
Monday - Friday, 8 a.m. to 11 p.m.
Saturday - Sunday, 9 a.m. to 5 p.m.
Comments
This field is for validation purposes and should be left unchanged.

Lorem ipsum dolor Comprehensive Cholesterol Screening Registration

High cholesterol is one of the major controllable risk factors for coronary heart disease, heart attack, and stroke. And since high cholesterol has no symptoms, the only way to know your cholesterol levels is by having them checked.

Register for your Comprehensive Cholesterol Screening by filling out the form below. Cholesterol Screenings are avaialble for $30 ($40 for nonmembers) at The Wellness Center. Included in the screening are Total Cholesterol, HDL, LDL, TC/HDL ratio, Triglycerides, Glucose, and Blood Pressure.
- First Name*
- Last Name*
- Membership Number
- Date of Birth*
  MM slash DD slash YYYY
- Gender*
  - Male
  - Female
- Marital Status*
  - Married
  - Single
  - Undisclosed
- Emergency Contact Name*
- Emergency Contact Number*
- Height*
- Weight*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
- Home Phone*
- Other Phone*
- E-Mail Address*
- Current Employer*
- Occupation*
- How would you like to be contacted?*
  - Phone
  - E-Mail
  - Letter
Questions? Call The EJGH Wellness Center at (504) 503-6868.
Comments
This field is for validation purposes and should be left unchanged.

Lorem ipsum dolor Guest Feedback Form

Lorem ipsum dolor Exercise is Medicine Request Form

Physician and health care provider instructions for the Wellness Center EIM program:
1. Assess patient's exercise habits and encourage patient to increase physical activity if appropriate.
2. Refer appropriate patients to the Wellness Center for Health & Fitness EIM Program (minimum age 15 yrs).
3. Complete form and fax to 504-503-6800 or fitness@ejgh.org. Patient will be called to schedule appointment.
4. You will receive confirmation of patients participation and progress in the program.
Patient's Information
- Name*
- D.O.B.*
  MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
- Phone*
- Email*
Patient completes 150 minutes/week of exercise and strength trains twice/week?*
- Yes
- No
- Reason for referral*
- Health concerns/restrictions*
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Health Care Provider
- Name*
- Practice*
- Fax*
Signature*
The Wellness Center for Health & Fitness EIM Program Includes:
1. Health Assessment.
2. Exercise prescription tailored in patients choice of environment and exercise preferences.
3. Nutritional Counseling
4. Three month membership to the Wellness Center
Email
This field is for validation purposes and should be left unchanged.

Lorem ipsum dolor Woman & Newborn Registration Form

Mothers-to-be who wish to deliver at EJGH should submit a pre-registration form.
You will be prompted to attach a copy of your ID and a copy of both the front and back side of your insurance card. Before beginning this pre-registration form, you may wish to have these scanned to a file on your computer, ready to upload. As an option, you may also fax to: (504) 503-5485; scan and email to: womanandchild@ejgh.org or if you would prefer, we will be happy to make these copies for you. Feel free to visit our Woman & Newborn area located on the 4th floor of the hospital.
Patient Information
- Name of OB/GYN Physician*
- Preferred Language*
- First Name*
- Last Name*
- Due Date*
  MM slash DD slash YYYY
- Email*
- Social Security number*
- Date of Birth*
  MM slash DD slash YYYY
- Maiden Name*
- City and State of Birth*
- Race*
- Religion*
- Employer*
- Occupation*
- Marital Status*
  If married, complete Spouse Information section below.
- Have you been treated at EJGH before?*
  - Yes
  - No
Home Address*
Street Address City State / Province / Region ZIP / Postal Code
- Phone*
Business Address*
Street Address City State / Province / Region ZIP / Postal Code
- Business Phone*
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Spouse Information
- First Name
- Last Name
- Date of Birth
  MM slash DD slash YYYY
- Social Security Number
- City and State of Birth
- Spouse Phone Number
- Employer
- Occupation
Spouse Home Address
Street Address City State / Province / Region ZIP / Postal Code
Spouse Business Address
Street Address City State / Province / Region ZIP / Postal Code
- Spouse Business Phone Number
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Emergency Contact Information
- First Name*
- Last Name*
- Relationship*
- Emergency Phone Number*
Address*
Street Address City State / Province / Region ZIP / Postal Code
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Primary Insurance Company
- Primary Insurance Company Name*
- Subscriber's Name*
- Group Name*
- Policy or Medicaid No*
Address*
Street Address City State / Province / Region ZIP / Postal Code
- Phone*
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Secondary Insurance Company
- Secondary Insurance Company Name
- Subscriber's Name
- Group Name
- Policy or Medicaid No
Address
Street Address City State / Province / Region ZIP / Postal Code
- Phone
Documents
Please send a copy of your ID and a copy of both the front and back side of your insurance card. Fax to: (504) 456-5485; scan and email to: womanandchild@ejgh.org or if you would prefer, we will be happy to make these copies for you. Feel free to visit our Woman & Child area located on the 4th floor of the hospital.
Phone
This field is for validation purposes and should be left unchanged.

Lorem ipsum dolor Media Distribution List Sign-up

Lorem ipsum dolor Healthy Lifestyles Membership Application

Please Note: Submitting this form does not finalize membership. Payment is due prior to becoming a member. Please call The Healthy Lifestyles Office at (504) 503-4066 to arrange for payment.
Applicant Details
- Applicant's Name*
- Applicant's Birthdate*
  MM slash DD slash YYYY
- Applicant's Sex*
  - Male
  - Female
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Co-Applicant Details
- Co-Applicant's Name*
- Co-Applicant's Birthdate*
  MM slash DD slash YYYY
- Relationship to Member*
- Co-Applicant's Sex*
  - Male
  - Female
Section Break
Contact Details
- Phone Number*
- Email Address*
- Marital Status*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Lifetime membership fee of $50 for first qualifying member, $25 for second member in the same household.

Notice of Privacy Practices: East Jefferson General Hospital offers assistance to its Healthy Lifestyles members with processing their East Jefferson General Hospital bills. Staff members are EJGH employees and serve in an adjunct capacity to the hospital's patient finance department. If you use the billing assistance service, Healthy Lifestyles staff will have access to your medical billing records contained in the EJGH records systems. Federal privacy laws will prevent Healthy Lifestyles from assisting you with processing your bills with any other healthcare organization. EJGH Healthy Lifestyles maintains a general membership listing. This listing does not contain any medical information on members. The list is used solely for administration of the Healthy Lifestyles program and is not used or disclosed for any other purposes.

East Jefferson General Hospital reserves the right to alter or discontinue this program. Members must be 21 years of age.

Please Note: Submitting this form does not finalize membership. Payment is due prior to becoming a member. Please call the Healthy Lifestyles Ofice at (504) 503-4066 to arrange for payment.
Name
This field is for validation purposes and should be left unchanged.

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Lorem ipsum dolor Authorization For Treatment

General Information

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Employer Information

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Reason(s) For Visit (Please select all that apply.)

Lorem ipsum dolor Comprehensive Cholesterol Screening Registration

Lorem ipsum dolor Guest Feedback Form

Lorem ipsum dolor Women & Newborn Birth Certificate Form

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Father's Information

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Mother's Information

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Race

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Parents of Hispanic Origin

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Education Level

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Pregnancy History

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Lorem ipsum dolor Exercise is Medicine Request Form

Patient's Information

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Health Care Provider

Lorem ipsum dolor East Jefferson Imaging Online Request

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My appointment preference is

HealthFinder Appointments & Referrals Form

Your Information

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Patient Information

Please schedule my appointment on:

Lorem ipsum dolor Woman & Newborn Registration Form

Patient Information

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Spouse Information

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Emergency Contact Information

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Primary Insurance Company

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Secondary Insurance Company

Lorem ipsum dolor Media Distribution List Sign-up

Lorem ipsum dolor Healthy Lifestyles Membership Application

Applicant Details

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Co-Applicant Details

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Contact Details

EJGH Livingwell

Integrative Medicine Program

PHYSICIAN REFERRAL FORM

Patient Information

For Ordering Physician Use Only

Form may be submitted online, faxed to: (504) 503-6800 or emailed to: livingwell@ejgh.org

East Jefferson General Hospital

ejgh.org/livingwell

Lorem Nutrition Counseling Application

Lorem Volunteer Application Form

Contact Information

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Personal Information

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Skills & Experience

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Availability

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Personal References (Relatives are not accepted.)

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Emergency Contact

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Employer

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