GMH Online Pre-Registration Form
117 Hospital Drive
Petersburg, WV 26847

Use this form to pre-register for your test, procedure, surgery, or delivery.

If you have services scheduled at Grant Memorial Hospital (GMH), please fill out the following form in it's entirety. If you have any questions about the online pre-registration process or would like to pre-register by telephone, please call GMH Pre-Registration Department at (304) 257-5815 x2246.

PLEASE NOTE: Online pre-registrations are checked Monday - Friday from 7:30am - 8:00pm. Please allow at least one business day before your appointment for your pre-registration form to be processed. If there is less than one business day before your appointment, please register by calling the pre-registration department at (304) 257-5815 x2246.

Before you begin the pre-registration form, you are encouraged to review GMH's "Notice of Privacy Practices." To review that information, please click here.

Begin Pre-Registration Form
Answer the following eight(8) questions to help us simplify this online form for you.
  1. The guarantor is the person who is guaranteeing payment (usually the same as the patient if the patient is over age 18). Is the patient the guarantor? YES NO
  2. Do you carry insurance? YES Self Pay, No Insurance
  3. Do you have secondary insurance? YES NO
  4. Do you have a third insurance? YES NO
  5. Are you insured by Medicare? YES NO
  6. What is the date of your appointment?
  7. Please Choose the service you are pre-registering for:

    *If your service is not listed, please contact pre-registration at (304) 257-5815 x2246.
  8. Agree to the terms and conditions? YES NO