Online Pre Registration - East Alabama Medical Center

Welcome to the East Alabama Medical Center Online Pre-Registration Service.

The Patient Registration Department of East Alabama Medical Center strives to provide the highest quality customer service while obtaining accurate patient data. We will work with other departments in our facility to meet the overall needs of our patients while providing easy access to our services.

For your convenience, you may Pre-Register for your upcoming visit by completing the online pre-registration form. When using the Pre-Registration service, please allow sufficient time for us to process your request.

When arriving at the Hospital, please bring:

Valid Photo ID
Insurance card and method of payment for deductibles/co-pays and non-covered charges.
Paperwork from your doctor

Please remember that this is Pre-Registration. Upon arrival to your appointment other information and signatures may be required in order to complete the registration process.

Step 1 of 3

Service Information

Date of appointment or service*

Diagnostic Testing

Surgery

Maternity

Other

OtherService

Procedure

Diagnosis

Date Symptoms Began*

Ordering Doctor*

Primary Family Physician

Check if injury was an accident?

Date of Accident

Accident Type

Patient Information

First Name*

Last Name*

Suffix

Address*

City*

State*

Zip*

Home Phone*

Alt/Cell Phone

Email*

Social Security*

Birth Date*

MaritalStatus

Race*

Are you an American citizen?

If Other

Would you like a clergy visit?

Denomination

Employment*

Occupation

Employer

Emp Address

Emp City

Emp State

Emp Zip

Emp Phone

Company Retired From*

Responsible Party Information is same as Patient Information

Responsible Party Information

First Name*

Last Name*

Suffix

Address*

County*

City*

State*

Zip*

Home Phone*

Alt/Cell Phone

Social Security*

Birth Date*

Employment*

Occupation

Employer

Emp Address

Emp City

Emp State

Emp Zip

Emp Phone

Company Retired From*

Emergency Contact Information

Emergency Contact Name*

Emergency Contact Phone*

Relation to Patient*

Primary Insurance Information

Do you have insurance?

Company Name*

Address

City

State

Zip

Phone

Subscriber Name*

Subscriber DOB*

Relation to Patient*

Policy Number*

Group Number

Check here if you have Secondary Insurance.

Secondary Insurance Information

Company Name

Address

City

State

Zip

Phone

Subscriber Name

Subscriber DOB

Relation to Patient

Policy Number

Group Number

The names of patients who are registered at EAMC appear in a daily directory. You have the option of having your name removed from the directory for privacy reasons. Please understand that removing your name means that if anyone calls for you, if flowers are delivered for you, or if someone comes to try to visit you at the hospital we will tell them that you are not here.

While you are at EAMC or EAMC-Lanier do you wish for your name to display in our directory?

Check here if we can correspond with you via this email address.

We understand that your privacy and security are of the utmost importance. For your peace of mind, your registration information is secure while being transferred to EAMC utilizing 128 bit Secure Sockets Layer (SSL) technology. This technology encrypts all of your personal information including social security number, name and address, so that it cannot be read as the information travels over the Internet. If you are experiencing technical problems submitting this online form, please contact EAMC Technical Support at (334) 528-6850.