Pre-Register for Your Visit

Register Now to Avoid Waiting Later!

Minimize your wait at the hospital by pre-registering in advance of your non-emergency appointment at a Carondelet hospital. You can pre-register online in the convenience of your home, at work or anywhere you have access to the Internet. It’s a convenient way to prepare for your visit before you ever get to the hospital.

To get started, simply fill out the form below. When you include a valid email address, we’ll send you a confirmation email that we have received your paperwork. We’ll also let you know if we need additional information.

Pre-Registration Disclaimer

If you elect to electronically submit a completed pre-registration form or any other information to Carondelet Health Network through this website, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or omissions in the data you provide. You agree to release and hold Carondelet Health Network and its affiliates (including its directors, officers, employees, shareholders, agents and representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of any information submitted electronically by you through this web site and from any errors or omissions in the data you provide. Additionally, the provision of any information to Carondelet Health Network by you through this website, including a completed pre-registration form, does not create or constitute any relationship between you and Carondelet Health Network, its affiliates, or any of the physicians on its staff, to which any privilege may attach.

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.

 

State or Country, if not U.S.
mm/dd/yyyy
999-99-9999
999-999-9999

Employment Information

999-999-9999

Admission Information

Are you a returning patient?

Are you pregnant?

mm/dd/yyyy

Spouse/Guarantor Information (Responsible Party)

999-999-9999

Emergency Notification

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
Best way to contact you?

Best time to contact you?


If there is a financial liability (i.e. Co-payment, deductible, etc.) what is your preferred method of payment?


Newsletter Registration