• Pre-Registration

    Please fill in the form below
  • 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 prompted to leave a voicemail and we will contact at our earliest convenience. Our office hours are Monday-Friday 9:00 am - 5:30 pm.

    Upon check in, please provide your insurance cards, a valid ID and advance directive (if applicable) to the receptionist. 


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  • 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.

  • Employment

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  • In case of emergency...

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  • If Patient is a Minor complete the following:

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  • Primary Insurance Information

  • Secondary Insurance Information

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

     

  • Provider

  • Complete This Portion for Maternity Admission

  • Should be Empty: