UnityPoint Health - St. Luke's Hospital

Pain Clinic Pre-Registration

To preregister for your lab test, please complete the following information and click Send. Preregistration should be completed 24-48 hours before your visit. Stop by outpatient registration (Mon.-Fri.) or the Emergency Department check-out desk (Sat.) to pick up your paperwork before you go to the lab. Please enter the hospital through the West Entrance for both registration and the lab.

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Patient Information


Marital Status
Gender
Race
Translation/Interpreter Services Needed?

Mailing Address


Employment Status (if applicable)

Emergency Contact Information



Insurance Information


Primary Insurance Company *
Secondary Insurance? (If yes, please complete section)

Other Information


Spiritual needs are important to some patients, would you like us to notify your Pastor of your admission?