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

*
*
*
*
* (use format MM/DD/YYYY)
*
*
*
*
*
*
(use format XXX-XXX-XXXX)
(use format XXX-XXX-XXXX)
(use format xxx-xx-xxxx)
*
*
(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

*
*
*
*
*
*
*
* (use format xxx-xxx-xxxx)
Do you have an advance directive or living will?

Contact Information

Person to Notify

*
*
*
*
*
*
*
* (use format xxx-xxx-xxxx)
(use format xxx-xxx-xxxx)

Other Emergency Contact

(use format xxx-xxx-xxxx)
(use format xxx-xxx-xxxx)

Primary Care Doctor *

Travel

*
*
*

Insurance Information

*

Primary Insurance Information

*
Since the patient is not the primary subscriber, we will need the subscriber's:
*
* (use format MM/DD/YYYY)
* (use format xxx-xx-xxxx)
*
(use format xxx-xxx-xxxx)
*
* (if Medicare, enter 'none')

Secondary Insurance Information

*
*
(use format xxx-xxx-xxxx)
*
*
If patient is not the subscriber, we will need the subscriber's:
(use format MM/DD/YYYY)
(use format xxx-xx-xxxx)

Complete This Portion for Maternity Admission

(use format MM/DD/YYYY)