Pre-Register for Your Visit

Please Pre-Register at Least 48 Hours in advance for any non-emergency appointment.

Are you scheduled for a medical procedure at Placentia-Linda Hospital? You can prepare for your visit before you ever get here. Just pre-register at least 48 hours in advance for any non-emergency appointment. You can fill out your paperwork in the comfort of your home, at work or anywhere you have access to a computer. 

To get started, simply fill out the form below. Include a valid email address, and we’ll send you confirmation that we’ve received your paperwork. We’ll also let you know if we need additional information. For assistance, call (714) 524-4872. 

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

Pre-registration disclaimer

If you electronically submit a completed pre-registration form or any other information to Placentia-Linda Hospital 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 Placentia-Linda Hospital 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 Placentia-Linda Hospital by you through this website, including a completed pre-registration form, does not create or constitute any relationship between you and Placentia-Linda Hospital, its affiliates or any of the physicians on its staff, to which any privilege may attach.

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?