Please fill out the following form at least three business days in advance of your hospital visit. Pre-registered patients must still report to the hospital admission desk upon arrival.
All items with an asterisk (*) are required. Memorial Community Health respects patient privacy and confidentiality and makes every effort to ensure that patient-specific information is secure under all circumstances.
I have elected to electronically submit a completed pre-registration form to Memorial Community Health, Inc. through the Memorial Community Health web site. I agree to do so at my own risk and assume all responsibility for any liability arising from such electronic transmission and from errors or omissions in the data I have provided. I agree to release and hold Memorial Community Health, Inc. and its affiliates harmless from any and all liability or cause of action arising from the interception, access or use by a third party of any information submitted electronically by me through this web site and from errors or omissions in the data I have provided. I understand that Memorial Community Health protects electronically submitted data through secure encryption and that the information I submit electronically as part of the pre-registration process will not be used for any purpose other than pre-registration.