The linked form is to register for our Patient Pre-registration Program. By registering with us you can receive peace of mind that we have your medical information.
Please Print clearly and Complete the following information. This form should take 4 or 5 minutes to complete.
NON-DISCRIMINATION CLAUSE: Provider will not discriminate based upon the individual’s race, color, sex, national origin, disability, religion, age, sexual orientation, or gender identity or ability to pay. Hardtner Medical Center offers a discounted sliding fee scale to all qualified patients.
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