Pre-Register for Your Visit

Before your stay, register online

Why rush to check in at the hospital, when you can pre-register online? Fountain Valley Regional Hospital and Medical Center allows you pre-register for hospital admissions, as well as medical procedures, X-rays, lab tests and the birth of a baby.

Register up to six months – and until 48 hours – before your admission. Use our online preregistration tool, or call (855) 946-3604 for assistance.

Pre-Registration

Please fill out the form below and we’ll confirm with you when received if you have included a valid email address. At that time we’ll also let you know if we need any additional information.

Fields marked with an asterisk(*) are required.

 

If not from USA, select "Outside U.S."
If not U.S.
mm/dd/yyyy
999-99-9999
999-999-9999
999-999-9999

Employment Information

999-999-9999

Admission Information

Are you a returning patient?*

Are you pregnant?

mm/dd/yyyy
mm/dd/yyyy

Spouse/Guarantor Information (Responsible Party)

If not from USA, select "Outside U.S."
999-999-9999

Emergency Notification

Emergency Contact

999-999-9999

Nearest Relative or Friend (not living with you)

999-999-9999

Primary Insurance Information

Are you insured?*

999-999-9999
999-999-9999
mm/dd/yyyy

Secondary Insurance Information

Do you have secondary insurance?*

999-999-9999
999-999-9999
mm/dd/yyyy
If there is a financial liability (i.e. Co-payment, deductible, etc.) what is your preferred method of payment?


Best way to contact you?

Best time to contact you?


Newsletter Registration

Pre-registration disclaimer

This is for the pre-registration of non-emergent patients only. Please submit this online pre-registration at least 48 hours in advance of your hospital check-in to ensure its timely process.

If you choose to utilize our pre-registration form, understand that you do so at your own choice and risk. Any information you submit via the pre-registration form is confidential and is only shared with third parties as outlined in our Privacy Pledge.

If you elect to electronically submit a completed pre-registration form or any other information to Fountain Valley Regional Hospital and Medical Center through this website, 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 omissions in the data you provide. You agree to release and hold Fountain Valley Regional Hospital and Medical Center 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 website and from any errors or omissions in the data you provide. Additionally, the provision of any information to Fountain Valley Regional Hospital and Medical Center by you through this website, including a completed pre-registration form, does not create or constitute any relationship between you and Fountain Valley Regional Hospital and Medical Center, its affiliates or any of the physicians on its staff, to which any privilege may attach.