Please note: This pre-registration is for inpatient and outpatient center visits only. This is not for doctors' offices.

Please fill out all the information below to the best of your knowledge. So that we may contact you with any questions, please be sure to include Patient / Contact information.

If you are pre-registering for services LESS THAN 48 hours in advance, please call as follows:

  • For hospital services, please call the Pre-Registration Department at 317-355-3920.
  • For Community Surgery or Endoscopy Centers, please call 317-621-1040.

Surgery/ Test /
Due Date:
(mm/dd/yyyy)
 
Facility: 
Procedure Type:
(Check all that apply.)









Symptoms/Diagnoses
Reason for Service:
 (e.g., Neck Pain)
While in the hospital,if someone asks, can we inform them of your location?
Patient First Name:
Patient Middle Name:
Patient Last Name:
Patient Former Last Name(s):
Patient Suffix:  (e.g., Jr. Sr.)
Patient Social Security Number:
Patient Gender:
Patient Race:
Patient Birth Date:
(mm/dd/yyyy)
Patient Marital Status:
Patient / Contact Email Address:
Patient Street Address:
Patient City:
Patient State:
Patient Zip Code:
Patient / Contact Home Phone:
Patient / Contact Daytime Phone:
Patient / Contact Cell Phone:
Patient Preferred Contact:
If there is no answer, can we leave a message for the patient?
Do you have an advanced directive?
IF no, please call 317-355-7100 to listen to your rights
If yes, the date:
(mm/dd/yyyy)
IF no, please call 317-355-7100 to listen to your rights
Patient Employment Status:
Patient Employer:
Patient Employer Address:
Patient Employer City:
Patient Employer State:
Patient Employer Zip Code:
Patient Occupation:
If patient military, which branch:
If patient retired, retirement date:
(mm/dd/yyyy)