Thank You for choosing us for your health care services. As a convenience, we offer online hospital pre-registration. We encourage you to preregister for scheduled services to ensure a quicker check-in process.
Note: Please pre-register at least 24 hours before your appointment.
Please fill out the entire form to the best of your ability. If there is no answer, enter N/A. Fields marked with an asterisk (*) are required.
Items You Will Need for Online Pre-Registration:
- Active insurance cards
- Patient and insurance subscriber’s Social Security numbers
- Physician order & physician’s information including (names, addresses, and phone number)
- Emergency contact information
Items You Will Need on Day of Admission:
- Active insurance cards
- Picture ID (Driver’s license)
- Physician order
- Co-payment/deductibles are expected at time of service unless prior arrangements are made. (We accept MasterCard, Visa and Discover cards)
Contact Us
Phone (319) 319-4120
Manager Becky David
Please use this form for hospital pre-registration only. This is not used for clinic visits.
