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Pre-Register Online

Thank you for choosing to pre-register!  Please note:  even if you pre-register, you will be asked to verify much of the information upon your arrival at the hospital for your procedure.  You will also need to present your insurance cards and a photo ID at this time.

To pre-register, please complete and submit this form at least 48 hours prior to your appointment.  Feel free to call 825-0869 with any questions.

Patient Information

*First Name


*Middle Name


*Last Name


*Date of Birth


*Home Phone


*Cell Phone


*Work Phone


*Address 1


Address 2


*City


*State


*Zip Code


Email


*Social Security Number (no dashes)


*Sex


*Marital Status


Smoker


*Employer Name


*Name of Primary Physician


*Physician/Provider that ordered this test or procedure


Emergency Contact Information

*First Name


*Last Name


Date of Birth (required if spouse)


*Address 1


Address 2


*City


*State


*Zip Code


*Home Phone


*Cell Phone


*Work Phone


*Relationship


(Complete this section if you have more than one emergency contact)

*First Name


*Last Name


Date of Birth (required if spouse)


*Address 1


Address 2


*City


*State


*Zip Code


*Home Phone


*Cell Phone


*Work Phone


*Relationship


Reason for Visit

*For which test/procedure are you scheduled?


Was this visit ordered due to an accident?


Insurance Information

If you do not have health insurance, and would like to speak to a Financial Counselor regarding payment options, please call (812) 825-0894.

*Do you have?


*Do you have Medicaid?


*Name of Insurance Company


*Name of the Insured


*Relationship to Patient


*Insured's Date of Birth


*Insured's Social Security Number (no dashes)


*Insured's Employer


*Insurance ID#


*Group/Account #