425 W. Fifth Street
East Liverpool, OH 43920
330-385-7200

Patient Pre-Registration

Please use the following form to Pre-Register for your tests and lab work at East Liverpool City Hospital. Please submit your pre-registration at least 24 hours prior to any scheduled procedure date (this does not pertain to emergency room visits). Pre-registrations submitted closer to the procedure date may not be processed in time for your procedure. Before you can pre-register, you must know the following details:

Who is your doctor ordering these tests?

What is your diagnosis from your doctor?

What tests did your doctor recommend?

If you do not know the answer to these questions, please call 330-385-7200 and ask for our helpful Pre-Registration staff.

Online Patient Pre-Registration Form
A field with a red asterisk (*) is a required field
First Name:	*
Middle Initial:
Last Name:	*
Patient Address:	*
City:	*
State:	*
Zip:	*
Email Address:	*
Home Phone Number:	*
Work Phone Number:
Date of Birth:	* (MM/DD/YYYY)

Primary Insurance Company:	*
Primary Insurance Address:	*
Policy Number:	*
Group Number:	* Note - if you do not have a group number, enter "N/A" and leave a note in the comment field below.

Secondary Insurance Company:
Secondary Insurance Address:
Policy Number:
Group Number:

Ordering Doctor:	*
All Applicable Diagnoses: Include all diagnoses given by your doctor. Separate multiple details by a slash ( / ).	*
All Tests: Include all tests requested by your doctor. Separate multiple details by a slash ( / ).	*
Date of test:	*

Question or Comments:
Please enter the code into the field: Please carefully enter the code in this black box into the field below it. It must be an exact match. If you DO NOT enter this information correctly, we may not receive your request!	*