Using our Online Pre-Admission Form
Please enter your information on the following pages.
The fields with an asterisk are required and must be completed in order for you to be able
to submit the form; if these fields are left blank, your registration won't be sent.
Memorial Medical Center assures protection of your personal health information.
Our website securely transfers your information to our data systems.
You can verify Memorial Medical Center is collecting your information over a
secure site by clicking on the padlock icon
located near your browser's address bar to view our certification form.
Memorial Medical Center is a not-for-profit organization,
and we recognize that medical bills are sometimes unexpected, and can be unaffordable.
Because of this, Memorial Medical Center has a
financial assistance program also known as Charity Care.
This program is designed to help patients that have no insurance, or limited insurance,
with their bills. Financial Assistance is based on income, assets, and other factors.
Confidentiality of information and individual dignity will be maintained for all that seek this service.
For specific information on our financial assistance program, please call our
Financial Assistance Analyst at (209) 569-7734 or
e-mail to firstname.lastname@example.org for an information packet and application.
Please be aware that we frequently approve Financial Assistance prior to providing
services as well as after services are rendered.