Pre-Registration Form

Methodist Emergency Department

First Available Time :

Pekin Emergency Department

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Proctor Emergency Department

First Available Time :

Pekin Urgent Care

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Express Care - Peoria

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Pre-Registration Form

Please fill out the form below.



Required fields indicated by *

Patient Information

Do you currently reside at your home? *
Date of Birth *
/ /
Date of Disability
/ /
Date of Retirement
/ /

Personal Details

Do you want visitors/phone calls during your visit? *
Do you have an allergy to latex? *
Do you have difficulty walking? *
Do you participate in any research program? *
Do you have power of attorney for healthcare? *
Do you have a living will? *
May we release information to your place of worship? *
If admitted, would you like a hospital chaplain to visit you? *

Visit Information

Date of Appointment *
/ /

Physician Information

Ordering Physician

Family Physician

Referring Physician

Accident/Injury Information

Is your visit due to accident or injury? *
Accident Type*

Location of Accident/Injury

Date of Accident/Injury *
/ /

Primary Emergency Contact

Is this contact the spouse or parent of the patient who is a minor? *
Date of Birth
/ /
Date of Disability
/ /
Date of Retirement
/ /
Would you like to add a second emergency contact? *

Secondary Emergency Contact

Is this contact the spouse or parent of the patient who is a minor? *
Date of Birth
/ /
Date of Disability
/ /
Date of Retirement
/ /

Primary Insurance

Insurance Type*

You have selected self pay. You are responsible for all payments.

Date of Birth
/ /
Date of Disability
/ /
Date of Retirement
/ /
Add Secondary Insurance*

Secondary Insurance

Insurance Type*

You have selected self pay. You are responsible for all payments.

Date of Birth
/ /
Date of Disability
/ /
Date of Retirement
/ /