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 1.877.444.2778 or locally at 724.357.7075.

*NOTE* This form is for preregistration. You must preregister at least 24 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.

*Indiana Regional Medical Center has affiliates who also use our electronic medical record system. Do we have your permission to search our affiliates to see if you have an existing record and use that record if found?

Service Information

*What date will you be arriving for services?

Month

Day

*Year:

*What procedure/test are you coming in for?

*Location of Service:

*Type of Service:

*Diagnosis (found on your physician script/can be verbiage or codes. Example: diabetes or ICD-10 code such as E119):

*Ordering physician name:

*Is this a fasting test?

Yes No

If receiving a CT, x-ray, ultrasound or MRI, please specify part of body to be scanned.

*What is your preferred pharmacy?

Personal or family physician name:

*Last:

*First:

Patient Information

Legal Name

*Last:

*First:

*Middle Initial:

Social Security Number:

*Sex:

*Date of Birth:

*Month

*Day

*Year

Mailing Address

*Street:

*Zip:

*City:

*State:

*Home Number:

Work Phone:

Cell Phone:

*Primary Phone:

E-mail Address (for use regarding only your care and appointments):

Marital Status:

Religion:

*Language:

What is your country of origin?

*Ethnic Group:

*Race:

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

*Are you employed?

Emergency Contact Information

*Last:

*First:

*Relation to Patient:

*Home Phone:

Work Phone:

Cell Phone:

Surgery Information

If possible, would you like a visit from your clergy?

Yes No

Name to appear in facility directory?

Yes No

Would you like a visit from an IRMC clergy and/or volunteer?

Yes No

Do you have an advance directive?

Yes No

Do you have a living will?

Yes No

Do you have a durable POA for health care decisions?

Yes No

Can you bring a copy with you?

Yes No

If no, who can bring it in?

Living Arrangements:

Alone Immediate Family Friends Student Group Home Other

If other, please specify:

Publish?

Yes No

Guarantor Information

(Person responsible for the bill.)

*Is the patient the same person as the guarantor?

Insurance Information

*Do you have Medicare?

*Do you have health insurance?

Accident Information

*Is this visit the result of an accident or injury?

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