This form is for patients to pre-register for Mary Lanning Healthcare procedures and office visits only
If you wish to sign up for the Vital Signs Health Fair, please click the Health Fair link at the top of the page and you will be directed to the Health Fair Registration form. Thank you!
Please fill out the following form at least 5-7 business days in advance of your hospital visit. Pre-registered patients must still report to the hospital admission desk upon arrival.
All items with an asterisk (*) are required. Mary Lanning Healthcare respects patient privacy and confidentiality and makes every effort to ensure that patient-specific information is secure under all circumstances.
I have elected to electronically submit a completed pre-registration form to Mary Lanning Healthcare through the Mary Lanning Healthcare web site. I agree to do so at my own risk and assume all responsibility for any liability arising from such electronic transmission and from errors or omissions in the data I have provided. I agree to release and hold Mary Lanning Healthcare and its affiliates 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 me through this web site and from errors or omissions in the data I have provided. I understand that Mary Lanning Healthcare protects electronically submitted data through secure encryption and that the information I submit electronically as part of the pre-registration process will not be used for any purpose other than pre-registration.
