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WellConnect - Columbus Regional Health


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.

Step 1 of 3

Patient Information

*First Name:
Middle Initial:
*Last Name:
*Date of Birth:
Format: mm/dd/yyyy
*Social Security Number:
- - Format: xxx-xx-xxxx
*Marital Status:
*Address 1:
Address 2:
Format: 555-555-1234
Phone Type:
Ext. Number:
May we leave a message at this contact number?
*Do you have insurance?

Spouse or Emergency Contact

*First Name:
*Last Name:
*Contact Number:
Format: 555-555-1234
*Relationship to Patient:

Employment Status

*Employment Status:

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Why Pre-Register

  • Confidential - Your info is kept private and secure.
  • Save Time - When you arrive at the hospital, your information has already been entered into the computer.
  • Keep Track - When you pre-register online, your registration history will be available for you to view anytime in your secure profile.
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