Patient Pre-Registration

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 astrisk (*) 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:

 


 

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