Ducan Regional Hospital


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Pre-Register Online

At Duncan Regional Hospital, we care about our patients time, and we realize your time is valuable.  If you have a scheduled appointment, please fill out this form to pre-register.  Please fill in as much information as accurately as you can, as this will speed up your process.  Someone in Patient Accounts will contact you after you submit your form, to complete the registration.
* Indicates required information
Do you have a scheduled appointment? * 
If yes, please state the date of service/due date: *    (mm/dd/yyyy)
Please select where your scheduled appointment is to take place. 
Family Physician 
Ordering Physician 
Patient Information 
Full Name (Last, First, Middle Name) * 
Street Address 1 * 
Street Address 2 
City * 
State * 
Zip Code * 
Date of Birth *    (mm/dd/yyyy)
Sex * 

Last 4 digits of Social Security Number * 
Home Phone * 
Work Phone 
Cell Phone 
Religion/Church 
Race * 
US Citizen 
Email Address 
Employment Status 
Employer Name 
Employer Address 1 
Employer Address 2 
Employer City 
Employer State 
Employer Zip 
Employer Phone 
Occupation/Job Title 
NEXT OF KIN 
Next of Kin Last, First Name 
Next of Kin Address 
Next of Kin City 
Next of Kin State 
Next of Kin Zip 
Next of Kin Home Phone 
Next of Kin Work or Cell Phone 
Relationship to Patient 
EMERGENCY CONTACT 
Person to Notify in Case of Emergency 
Address 
City 
State 
Zip 
Home Phone  
Work or Cell Phone 
Relationship to Patient 
GUARANTOR - Skip if patient is Guarantor 
Guarantor: 

Guarantor's Last, First Name  
Guarantor's Address 
Guarantor's City 
Guarantor's State 
Guarantor's Zip 
Guarantor's Last 4 digits of SSN 
Guarantor's Email Address 
Guarantor's Employer 
Guarantor's Employer Address 
Guarantor's Employer City 
Guarantor's Employer State 
Guarantor's Employer Zip 
Guarantor's Employer Phone 
Guarantor's Occupation/Job Title 
Guarantor's Employment Status 
PATIENT INSURANCE 
Patient Insurance - Please see below 

If Other, please specify:
Insurance Name 
Insurance Address 
Insurance City 
Insurance State 
Insurance Zip 
Insurance Phone 
Insurance Policy Number 
Insurance Group # 
Insurance Group Name 
Subscriber Relationship to patient 
Subscriber - Effective date of coverage    (mm/dd/yyyy)
Subscriber Employment Status 
Subscriber Employer Name 
Subscriber Employer City 
Subscriber Employer State 
Subscriber Employer Zip 
Subscriber 
SUBSCRIBER - if other than self 
Subscriber Name 
Subscriber Address 
Subscriber City 
Subscriber State 
Subscriber Zip 
Subscriber Phone 
Subscriber Email 
Subscriber Date of Birth    (mm/dd/yyyy)
Subscriber Gender 
Subscriber - Last 4 of Social Security # 
Marital Status 
Race 
U.S. Citizen 
Authentication * 

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Duncan Regional Hospital    1407 Whisenant Dr.    Duncan, OK 73533    (580) 252-5300    Information at Duncan Regional Hospital
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