Before Your Stay

Pre-Registration

Use the form below to pre-register! If you are a maternity patient, please click here to pre-register.

Appointment Information
Ordering Physician

Reason for Visit

Heart Station
Infusion Care Services
Rehab Services
Women's Center
X-Ray/Diagnostic Imaging
Maternity (The Birth Place)
Expectant mothers, click here for our maternity pre-registration form
If you are unsure what to check above, please describe the reason(s) your physician is sending you to us here:
Expected date of appointment/admission (delivery date, if pregnant)
*Note: Appointment must be scheduled prior to pre-registration. Please pre-register by 3pm the day before your procedure.
Patient Information
First Name
Last Name
Middle Initial
Maiden Name
Suffix
Email Address
Phone Numbers
Primary
Other
Address
Street Address
 
City
State
Zip
Have you been treated at Iredell Memorial Hospital before?
Have you been here under a different name?
What name?
Date of Birth
Social Security
Gender
Marital Status
Religious Affiliation
Race
Employment Status
Occupation
Employer
Work Phone
Employer Address
Street Address
 
City
State
Zip
Responsible Party
Name
Responsible Party
If age 18 or over, select SELF and skip to Emergency Contact #1
Address
Street Address
 
City
State
Zip
Phone
Relationship to Patient
Employer
Employer Phone
Emergency Contact #1
Name
Address
Street Address
 
City
State
Zip
Phone Numbers
Primary
Other
Relationship to Patient
Employer
Employer Phone
Emergency Contact #2
Name
Address
Street Address
 
City
State
Zip
Phone Numbers
Primary
Other
Relationship to Patient
Employer
Employer Phone
Allergy Information
Please list any allergies and reactions below
Allergies and Reactions
Primary Insurance Information
Name of Insurance
Address
Street Address
 
City
State
Zip
Phone
Effective Date
Group Number
Group Name
Policy Number
Policyholder
Social Security Number
Date of Birth
Does this insurance require pre-authorization?
Phone Number for Pre-Authorization
Secondary Insurance Information
Name of Insurance
Address
Street Address
 
City
State
Zip
Phone
Effective Date
Group Number
Group Name
Policy Number
Policyholder
Social Security Number
Date of Birth
Does this insurance require pre-authorization?
Phone Number for Pre-Authorization
*Please make sure that you bring all of your insurance cards on the day of your visit.
Submit