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Read More About Alamance Regional's Inspiring Care Stories
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Do you have a story of Inspiring Care you or a loved one experienced at Alamance Regional? We'd love to hear it.
Do you have a story of Inspiring Care you or a loved one experienced at Alamance Regional? We'd love to hear it.
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This form should only be used by patients who want to Pre-Register for Scheduled appointments or Labor and Delivery. It is not intended for use by Emergency Room patients or Urgent Care patients.

Thank you for pre-registering at Alamance Regional, please fill out the following form in order to complete the pre-registration process.

Step 1: Please complete the following patient information.

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  First Name:
  Middle Name:
  Last Name:
  Sex: Male  Female
Name Given on Previous Admission:
  Address:
  City:
  State:
  Zip Code:
  County:
  Phone:
  SSN:
  SSN is secure and encrypted.
  Marital Status: Single Married Divorced
Widowed Separated
  Birthdate:
  Race:
Religion:
Church:
Employer's Name:
Employer Mailing Address:
Employer City:
Employer State:
Employer Zip:
Occupation:
Do you have an Advance Directive or Living Will? Yes No
Date Employment or Retirement/Disability Began:
Employment Status: Retired Student Disabled Part-Time
Full-Time Self-Employed Unemployed
 
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