U-Reg

on-line patient pre-registration

UC Health
1 2 3 4 Review
Appointment Information

  * Required fields Complete Form for Hospital Services Only
Person completing this form:
Your relation to patient:
* Expected date of visit:
Facility:
E-mail Address:
* Primary care physician:
Admitting/treating physician:
Has patient received services at a UC Health facility before?
First Name
M
Last Name
Suffix

[necessary if you want email confirmation]
First Name
Last Name
First Name
Last Name


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