Your browser does not support JavaScript!
This form cannot automatically check that you have submitted all of the required fields without JavaScript.
Please be sure to submit all required fields (marked with stars).

Anderson Regional Medical Center

Online Pre-registration Form

Please use this form to help us prepare for your visit to Anderson Regional Medical Center. By registering with us you can receive peace of mind that we have your medical information, and streamline your processing in our admissions department.
Fields marked with an "*" are required.
* Last Name:
  Middle Initial:
* First Name:
* Date of Birth:
* SSN:
* Contact Phone Number:
  Address:
  City, State, Zip:
  Employer:
* Have you been out of the country within the last 21 days? Yes     No    
  If yes, where?
Please name country or countries.
  Name of Doctor:
* Date of Procedure:
* Type of Procedure:
If you chose "Surgery" and have not visited our nursing staff at Anderson Regional Medical Center for any pre-surgery clearance tests, please contact (601) 553-6924 or (601) 553-6847
  If "Other", please type name:
  If you chose "Surgery", what type of Surgery?
  Facility: Anderson North     Anderson South    
* Type of Insurance (Primary):
If you do not have insurance, please contact the Outsource Group at 601-553-6877 for Financial Assistance Application
  If "Other", please type name:
  If Medicare, please choose: Traditional     Advantage(Windsor;Humana;UnitedHealth Care;etc.)     Are you being treated by a home health or hospice nurse?    
* Primary Policy #:
  Primary Group #:
* Insured Name / Date of Birth:
  Type of Insurance(Secondary):
  If "Other", please type name:
  Secondary Policy #:
  Secondary Group #:
  Insured Name/ Date of Birth: