Online Pre-Registration

Published On 07/11/2011

Please fill out your online pre-registration at least two (2) full business days before your scheduled visit. Once we receive your online form, Admissions will process your pre-registration. We may contact you if we need more information.

If you are pre-registering less than two full days before your visit, please call the location of your appointment during business hours. 

Register For:

Before You Register

To complete your registration form, you will need:

  • Patient information—Name, address, phone number(s), Social Security number, date of birth
  • Patient employer information (if applicable)—Employer name, address, phone number
  • Alternate contact information—Name, phone number(s) of contact person (preferably, someone who does not live at your address)
  • Your physician information—Name of your primary care physician or family physician
  • Insurance information (if applicable)—Insurance company name, address, subscriber’s name, Social Security number, policy ID number and Group ID number (this is information shown on the subscriber’s insurance card)
  • Financially responsible person information—Name, address, Social Security number, date of birth, phone number(s), employer name and employer address
  • Accident details (if your visit is related to a recent accident)—Description of accident, including date of accident/injury, liability insurance company name, address and phone number