Lorem ipsum dolor Authorization For Treatment

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.

    • Date Format: MM slash DD slash YYYY
  • Questions? Call The EJGH Wellness Center at (504) 503-6868.
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Lorem ipsum dolor Guest Feedback Form

Lorem ipsum dolor Women & Newborn Birth Certificate Form

  • Please complete the following information. This will enable us to promptly process the official birth certificate after you deliver your baby

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  • Father's Information
    • Date Format: MM slash DD slash YYYY
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  • Mother's Information
    • Date Format: MM slash DD slash YYYY
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  • Race
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  • Parents of Hispanic Origin

    If yes, please specify Mexican, Puerto Rican, Cuban, etc.

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  • Education Level
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  • Pregnancy History
    • Date Format: MM slash DD slash YYYY
    • Spontaneous or induced at any time after conception. (specify zero if none)
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    • Date Format: MM slash DD slash YYYY
    • Date Format: MM slash DD slash YYYY
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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
    • Date Format: MM slash DD slash YYYY
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  • Health Care Provider
  • 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
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Lorem ipsum dolor East Jefferson Imaging Online Request

  • We understand that busy days with work and kids can make you forget about that appointment you have been meaning to schedule. Therefore, we have designed the online appointment request form for you to fill out. Call (504) 885-4223 or send an appointment request using our secure form and someone from our patient access department will respond promptly to your request. Patients needing an x-ray or lab performed at East Jefferson Imaging Center can walk in without an appointment.

    Please remember to bring with you at the time of your visit:
    1. Picture ID
    2. Insurance Information
    3. Signed Physician Order

    Disclaimer: This is not an official signed physician order. A signed physician order is required before your appointment arrival. This is meant as a request. Following a phone call from patient access, your official date and time will be confirmed.

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  • My appointment preference is
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HealthFinder Appointments & Referrals Form

  • Welcome to East Jefferson General Hospital's online physician appointment and referral service. We are available to provide physician appointments or referrals, Monday through Friday from 8 am to 4:30 pm. After hours and on weekends, we will respond to your request within two hours of the start of the next business day. If this is urgent, please call (504) 503-7000 during regular hours to speak with a HealthFinder Representative for immediate help. If this is an emergency, please call 911 or proceed to the nearest emergency room. For more information on our physician appointment and referral service, please call (504) 503-7000.
  • Your Information
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  • Patient Information
    • Date Format: MM slash DD slash YYYY
  • Please schedule my appointment on:
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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
    • Date Format: MM slash DD slash YYYY
    • Date Format: MM slash DD slash YYYY
    • If married, complete Spouse Information section below.
  • Spouse Information
    • Date Format: MM slash DD slash YYYY
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  • Emergency Contact Information
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  • Primary Insurance Company
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  • Secondary Insurance Company
  • 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.

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Lorem ipsum dolor Media Distribution List Sign-up

  • Sign up for our media distribution list to receive e-mailed press releases and other hospital updates from the Public and Media Relations Department.

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
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  • Co-Applicant Details
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  • Contact Details
  • 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.

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EJGH Livingwell

Lorem Nutrition Counseling Application

Lorem Volunteer Application Form

  • Please complete this application form if you are interested in becoming an East Jefferson General Hospital volunteer. Once you complete the form, someone from our Volunteer Services department will be in touch. Thank you!
  • Contact Information
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  • Personal Information
    • Date Format: MM slash DD slash YYYY
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  • Skills & Experience

    Check all that apply.

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  • Availability

    Please indicate the days and times you are usually available to volunteer. Shifts include morning (8-12n), afternoon (12n-4p) and evening (4-8p). Flexible hours are available.

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  • Personal References (Relatives are not accepted.)
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  • Emergency Contact

    In the event of an emergency whom should we notify?

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  • Employer

    Please list your current or most recent employer, if applicable.

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  • I Agree

    I understand and agree that submitting this application form does not automatically register me as a East Jefferson General Hospital volunteer, and that there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures before I may begin volunteering, including but not limited to a minimum committment of 50 hours of service.

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