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PATIENTS & VISITORS

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Pre-Registration

Pre-registration is available and recommended for anyone checking into Jefferson Regional Medical Center. Once you pre-register, much of your information will be prepared ahead of your arrival. To pre-register, complete the form below.

Please note: pre-registration is not a request for an appointment.

Patient Information

Marital Status:      

**If married, please enter spouse information**



Patient Employer Information:



Reason for Visit



Guarantor Information



Insurance Information