Hospital Patient Registration Form

Prior to your scheduled service or admission, we suggest you complete our pre-registration form. Below is our secure and HIPAA compliant form. Completing this in advance minimizes your check in time and allows us to assist you with financial arrangements as needed. Please submit the completed form at least 3 business days prior to your scheduled services. If you choose to fill out the form less than 3 days before your date of service, you may be asked similar questions upon arriving for your appointment. Keep in mind, if you fill out the form during non-business hours, your information will not be reflected until the next business day.

If you prefer to pre-register over the phone, please contact us at 608-643-7528. You will be required to leave a voicemail and we will contact you back at our earliest convenience. Our office hours are Monday-Friday 9:00 am - 5:30 pm.

Reason for Visit *

Inpatient Surgery Outpatient Visit

Patient Name *

First Name Middle Name Last Name

Date of Birth *

Month Day Year

Age

Sex *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number - Primary *

Area Code Phone Number

Phone Number - Secondary

Area Code Phone Number

E-mail (required if you want to access your health record securely online?

Receive E-mails? (Y/N)

Marital Status *

SSN (use format xxx-xx-xxxx)

Sauk Prairie Healthcare does not discriminate against patients due to race or ethnicity. The Federal Government has provided new guidelines for collecting the following information.

Race *

Ethnicity *

Preferred Language *

Do you have Advance Directives (Living WIll)? (Y/N)

Employment

Current Employment Status *

Employer Name (NA if Unemployed or Retired) *

Employer Phone

Area Code Phone Number

Employer Address

In case of emergency...

Primary Emergency Contact *

First Name Last Name

Address:

Contact Number *

Area Code Phone Number

Relationship *

Secondary Emergency Contact:

First Name Last Name

Address

Contact Number

Area Code Phone Number

Relationship

If Patient is a Minor complete the following:

Guarantor Name

First Name Last Name

Guarantor Address

Guarantor Phone

Area Code Phone Number

Relationship to Minor

Guarantor Employment Status

Guarantor Employer Name

Guarantor Employer Address

Guarantor Employer Phone

Area Code Phone Number

Primary Insurance Information

Do you have insurance? *

Yes No

Is the patient the primary insurance subscriber? *

Yes No

Primary Insurance Name *

Policy Number *

Group Number

Insurance Phone Number

Secondary Insurance Information

Do you have secondary Insurance? *

Yes No

Secondary Insurance Name

Policy Number

Group Number

Insurance Phone Number

If the patient is not the subscriber, please provide insurance subscriber's information:

Name

Birthdate

SSN (use format xxx-xx-xxxx)

Relationship to Patient

Provider

Primary Care Provider *

Provider Location

Complete This Portion for Maternity Admission

Expected Delivery Date (use format MM/DD/YYYY)

Admitting Doctor

Baby Last Name

Baby Doctor

Additional Notes

Pre-Registration