Pre-Register for Your Visit

Pre-registering for your visit can save you time when you get to the hospital. Use the form below to get started.

 

Pre-Registration

Please fill out the form below and we’ll confirm with you when received if you have included a valid email address. At that time we’ll also let you know if we need any additional information.

Fields marked with an asterisk(*) are required.

 

If not from USA, select "Outside U.S."
If not U.S.
mm/dd/yyyy
999-99-9999
999-999-9999
999-999-9999

Employment Information

999-999-9999

Admission Information

Are you a returning patient?*

Are you pregnant?

mm/dd/yyyy
mm/dd/yyyy

Spouse/Guarantor Information (Responsible Party)

If not from USA, select "Outside U.S."
999-999-9999

Emergency Notification

Emergency Contact

999-999-9999

Nearest Relative or Friend (not living with you)

999-999-9999

Primary Insurance Information

Are you insured?*

999-999-9999
999-999-9999
mm/dd/yyyy

Secondary Insurance Information

Do you have secondary insurance?*

999-999-9999
999-999-9999
mm/dd/yyyy
If there is a financial liability (i.e. Co-payment, deductible, etc.) what is your preferred method of payment?


Best way to contact you?

Best time to contact you?


Newsletter Registration

If you have any questions, call the Admitting office at (561) 694-7115.

Online ER registration

If you’re facing an emergency that’s not life-threatening, you can reduce your wait time at the ER by registering ahead of time with ER Check In Online, an online tool dedicated to emergency service.

Digital imaging scheduling

Schedule diagnostic imaging services by calling (561) 694-7163. Imaging service hours are 8 a.m. to 5 p.m., Monday through Friday. You’ll need a physician referral to make an appointment. For your convenience, same-day appointments are available. Any questions about testing, procedures, or requests for imaging records can be answered by calling (561) 694-7180.