Pre-Registration

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 prefer to pre-register over the phone, please contact us at 608-643-7528.  We are available to assist you Monday-Friday 9:00 am - 5:30 pm.

Patient Information

*
*
*

*
*
*
*
*
*



*
*
(required if you want to access your health record securely online)
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.


Employer Information

*
*
*
*
*
*
*
*

Contact Information

Person to Notify

*
*
*
*
*
*
*
*

Other Emergency Contact










Primary Care Doctor *

Have you traveled to West Africa in the last 21 days?*
Have you had contact with Ebola Virus Disease?*

Insurance Information

Primary Insurance Information

Do you have insurance?
*





*
*
If patient is not the subscriber, we will need the subscriber's:



Secondary Insurance Information









If patient is not the subscriber, we will need the subscriber's:



Complete This Portion for Maternity Admission