Welcome to Carle Richland Memorial Hospital's online pre-registration form. Pre-registration online should be done at least 24 hours in advance of your hospital visit. You will still need to visit the Admitting/Registration department when you come to the hospital in order to get your armband and any paperwork you need for your test, procedure or hospital stay. However, your time in the Admitting department will be shorter because all of your information has been obtained ahead of time on this form.
If you have any questions about this form or the online pre-registration process, please contact the Admitting/Registration Department at (618) 395-7340, extension 4625. Thank you.
SPOUSE’S EMPLOYER INFORMATION
IN CASE OF AN EMERGENCY
IF PATIENT IS UNDER THE AGE OF 18
GUARANTOR’S EMPLOYER INFORMATION
PRIMARY INSURANCE INFORMATION
SECONDARY/SUPPLEMENT INSURANCE INFORMATION