Registration

At Placentia-Linda Hospital, we provide convenient online registration tools – whether you’re visiting the Emergency Room or pre-registering for a longer hospital stay. These tools allow you to complete paperwork ahead of your visit. 

Our online registration is available for Emergency Room check-in, and scheduled hospital stays.

HOSPITAL PRE-REGISTRATION

Patients must register 48 hours in advance for any non-emergency appointment.

Fields marked with an asterisk (*) are required.

State or Country, if not U.S.
Enter using mm/dd/yyyy format
xxx-xx-xxxx

Employment Information

Admission Information

Are you a returning patient?
Enter using mm/dd/yyyy format

Spouse/Guarantor Information (Responsible Party)

Example 123-456-7890

Emergency Notification

Example 123-456-7890
Example 123-456-7890

Primary Insurance Information

Are you insured?
Enter in mm/dd/yyy format

Secondary Insurance Information

Do you have secondary insurance?
Best Way to Contact You

Best Time to Contact You


If there is a financial liability (i.e. Co-payment, deductible, etc.) what is your preferred method of payment?


Prepare for your visit to Placentia-Linda before you get here. Just fill out our online pre-registration form. 
If your medical situation isn’t critical, you don’t have to wait in Placentia-Linda’s  ER. Just schedule your visit online.