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Pre-register for Care at Wesley Long Hospital

IMPORTANT: Please only enter information that is 100% accurate.  If you are uncertain of the answer to any of the required questions, please do not use this form.  Incorrect entries could delay processing of your admission.

* Denotes required fields

Appointment Information

* Is this an inpatient or outpatient procedure?

Patient Information

* Were you born at or have you ever been treated at Moses Cone Hospital, Wesley Long Hospital, Women's Hospital, Annie Penn Hospital or the Behavioral Health Hospital?
Are you diabetic?
* Are you under 18 years of age?

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