Welcome to 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 RMH Admitting/Registration Department at (618) 395-7340, extension 4625.  Thank you.

 

PATIENT INFORMATION

 
 
 
 
 
 
 
 
 
 
 
 
 
 

EMPLOYER INFORMATION

SPOUSE INFORMATION

SPOUSE’S EMPLOYER INFORMATION

IN CASE OF AN EMERGENCY

 
 
 
 
 
 
 
 

IF PATIENT IS UNDER THE AGE OF 18

GUARANTOR DEMOGRAPHICS

GUARANTOR’S  EMPLOYER INFORMATION

PRIMARY INSURANCE INFORMATION

SECONDARY/SUPPLEMENT INSURANCE INFORMATION