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Indiana Regional Medical Center

Patient Preregistration

Our online patient registration form is secure, to protect your identity and personal information.

By Pre-Registering you will be able to report to the “Check–In” area.

If your testing requires a scheduled appointment, you must call the Scheduling Center at 1.888.452.4762 or locally at 724.357.7075.

*NOTE* This form is for preregistration. You must preregister at least 48 hours before your appointment time.

*NOTE* If you are preregistering for surgery, you also need to complete the pre op questionnaire.

All fields marked with an * are required.

Service Information

*What date will you be arriving for services?
Personal or family physician name:

Patient Information

Legal Name
*Date of Birth:
Mailing Address

You may be asked to provide this at time of registration.

Emergency Contact Information

Surgery Information

Guarantor Information

(Person responsible for the bill.)

Insurance Information

Accident Information