To make your registration at DHR as fast and easy as possible, please complete and submit the following pre-registration form.
This form shall only be utilized for direct admit patients to DHR and shall, under no circumstance, be utilized for any emergency patient cases. In the event of an emergency patient case, please send the patient directly to the Emergency Room.
Please be sure to enter all direct admit patient information correctly. DHR shall not be responsible for any delays in the registration process that may result from the incorrect submission of any information through this system.
Please be advised that this form will only serve to pre-register direct admit patients. The Physician Office will be required to call DHR Bedboard prior to use of this system and patients will still be required to personally present to DHR with personal identification and insurance information to fully register prior to admission at DHR.
Please note that completion and submission of this form does not guarantee admission or a bed at DHR.
Please enter full legal name.
Please enter information regarding the patient’s stay.
If uninsured, please type "none" in the insurance Company Name.
We will contact you within 30 minutes of receiving this information to provide a visit ID. Please enter your contact information.