Online Pre-Registration Form
Please fill out the information below.
Important Note: This Pre-registration form must be completed and submitted at least 24 hours in advance of your estimated arrival date and time.
This should be someone outside of the home
Pre-registration Disclaimer (MUST READ)
Email communication on the internet may NOT be secure. Children's of Alabama (Children's) makes no warranty, express or implied, regarding the security of any information to be submitted to it through web site. There is a risk that confidential information submitted by you to Children's through this web site, including a completed Pre-registration Form, may be intercepted illegally by a third party. If you elect to electronically submit a completed Pre-registration Form, or any other information, to Children's through this web site, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission or from any errors or omissions in the data you provide. You agree to release and hold Children's (and its employees, medical staff, agents, and/or representatives) 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 you through this web site and from any errors or omissions in the data you provide. Additionally, the provision of any information to Children's by you through this web site, including a completed Pre-registration Form, does not create or constitute any relationship between you and Children's (and its employees, medical staff, agents and/or representatives) to which any privilege may attach. By voluntarily submitting my information, I agree to this pre-registration disclaimer.
Before clicking the submit button, please review your information. You will not have the opportunity to edit it.