Online Pre-Registration

Please complete this form at least 24 hours before your visit to allow adequate time for processing your information.

If your appointment is within 24 hours, please use phone pre-registration: 812-375-3718 or 1-800-841-4938 ext. 3718. Phone registration is available Monday - Friday from 9 AM - 8 PM.

Additional Notes:
  • A confirmation email will be sent that will have directions on where to go upon arrival to the hospital.
  • Remember to bring your insurance card(s) and photo ID with you.

Patient Information

Please enter patient's first name
Please enter patient's last name
Please enter patient's valid date of birth
Please enter patient's valid social security number
Please choose patient's marital status
Please choose patient's gender
Please choose patient's race
Please enter patient's address
Please enter patient's city
Please choose patient's state
Please enter patient's zip code
Please enter patient's valid phone number in the format 555-555-5555
Please choose patient's phone type
Please enter patient's valid email address
Please choose whether you have insurance

Spouse or Emergency Contact
Please enter emergency contact's first name
Please enter emergency contact's last name
Please enter emergency contact's valid phone number in the format 555-555-5555
Please enter emergency contact's relationship to patient

Employment Status
Please enter patient's employment status
Please enter employer name
Please enter employer address
Please enter employer city
Please enter employer state
Please enter employer zip code
Please enter employer's valid phone number
Please enter school name
Please enter school city
Please enter school state
Please choose student status