Patient Pre-registration
Help us speed up the registration process by preregistering in advance of your scheduled service date.
Any information you submit online is confidential and is only shared with third parties outlined in our Privacy Pledge. For more information, please read our Privacy Pledge.
You may pre-register by completing our online registration form at least (3) business days in advance of your requested procedure date. Online preregistration is available for all scheduled inpatients and outpatients and OB for delivery.
On the day of your appointment:
Arrive 30 minutes prior to your appointment
Stop at Registration to complete your paperwork
Bring your insurance card(s), photo ID and orders from your physician
Prepare to pay any co-pays, deductibles, etc.
You can also preregister by phone by calling
304-431-5118 Monday-Friday 9:30am-5pm
Thank you for entrusting your healthcare needs to us.
Legal Disclaimer
Pre-Registration Disclaimer
The online pre-registration process requires that you answer confidential health information that is needed to complete your request and shall be utilized only for expediting registration. Your information will be secured by encryption software. While unlikely, it is possible that this information could be intercepted by non-authorized individuals engaging in illegal internet activities.
If you elect to electronically submit a completed pre-registration form or any other information to Princeton Community Hospital through this web site, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or ommissions in the data your provide. You agree to release and hold Princeton Community Hospital and its affiliates (including its directors, officers, employees, shareholders, agents and representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of any information submitted electronically by you through this web site and from any errors or omissions in the data you provide. Additionally, the provision of any information to Princeton Community Hospital by you through this web site, including a completed pre-registration form, does not create or constitute any relationship between you and Princeton Community Hospital, its affiliates, or any physicians on its staff, to which any privilege may attach.
To proceed, you must consent to these terms:
I Agree
I Disagree
10% Completed
Enter your visit information
My Appointment
Do you have an Appointment already scheduled for this visit?
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(Choose One)
Yes
No
If you are not an OB patient and do not have an appointment already, you must register upon arrival.
Appointment Type
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(Choose One)
Surgery
OB Admission
Outpatient Testing
Do you have a copy of the physician’s order?
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(Choose One)
Yes
No
Location Of Visit
Type Of Testing
Date of Service:
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Expected Delivery Date:
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Click here if this visit is due to an accident
How long have you had the symptoms?
Accident Summary
Accident Type:
(Choose One)
Auto Accident
Other
Hurt At Work
Accident Date:
Accident Location:
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Enter your physicians
My Ordering Physician
First Name
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Middle Initial:
Last Name
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My Family Physician
First Name:
Middle Initial:
Last Name:
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Enter your personal information
My Personal Information (Legal Name)
First Name
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Middle Initial:
Last Name
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:
Suffix:
ssn (last 4 digits):
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Date of Birth:
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Gender:
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:
(Choose One)
Male
Female
Marital Status:
Divorced
Legally Seperated
Life Partner
Married
Single
Widowed
(Choose One)
My Spouse
First Name:
Middle Initial:
Last Name:
Suffix:
My Spouse's Employer
Name:
City/State:
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Enter your contact information
My Mailing Address
Address:
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:
City:
*
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State:
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:
(Choose One)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
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My Phone Numbers
Home Phone
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Work Phone:
Mobile Phone:
My Email
Email Address:
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Enter the patients family information
Patient's Father
First Name:
Middle Initial:
Last Name:
Date of Birth:
Employer:
Patient's Mother
First Name:
Middle Initial:
Last Name:
Date of Birth:
Employer:
Are the child's parents divorced?:
(Choose One)
Yes
No
Custodial Parent:
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Enter your emergency contact
My Emergency Contact
First Name
*
:
Last Name
*
:
Relationship:
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:
(Choose One)
Child
Grandparent
Mother
Significant Other
Spouse
MPOA
Other
Self
My Emergency Contact's Address
Address:
City:
State:
(Choose One)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
My Emergency Contact's Phone Numbers
Home Phone:
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Work Phone:
Mobile Phone:
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Enter your employment information
My Employment Status
Employment Status:
Retired
Disabled
Student
Employee Full Time
Employee Part Time
Unemployed
(Choose One)
Self Employed
My Retirement Information
Date Retired:
Other Information
Date Disabled:
Other Information
Name of School:
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:
My Employer
Employer:
Address:
City:
State:
(Choose One)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Other Information
Name of Business
City:
State:
(Choose One)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Enter your primary insurance information
My Primary Insurance
I have insurance
I DO NOT have insurance
Policy Information
Insurance Name
*
:
Policy Number:
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:
Group Number:
Policyholder Name:
Date of Birth:
*
:
Relationship Type:
(Choose One)
Child
Grandparent
Mother
Significant Other
Spouse
MPOA
Other
Self
90% Completed
Enter your secondary insurance information
My Secondary Insurance
I have secondary insurance
I DO NOT have secondary insurance
You must click “Finish” to complete your preregistration
Policy Information
Insurance Name
*
:
Policy Number:
*
:
Group Number:
Policyholder Name:
Date of Birth:
*
:
Relationship Type:
(Choose One)
Child
Grandparent
Mother
Significant Other
Spouse
MPOA
Other
Self
You must click “Finish” to complete your preregistration
