Pre-Registration

763-577-7200

To streamline the patient check-in process, please complete the online pre-registration form below at least two business days prior to your appointment. If it is less than two days before your scheduled visit, or you opt not to complete pre-registration online, you may call WestHealth at 763-577-7200 to pre-register. Our registration department may also attempt to contact you by phone.

You may also register in person the day of your visit. If you have not pre-registered, please arrive at least 15 minutes prior to your scheduled appointment.

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Make sure all required fields(*) are filled in.

Type of Visit *

Date of Visit *

Calendar

First Name *

Middle Initial

Last Name *

Social Security Number #

Date Of Birth *

Gender *

Street Address *

Apt/Unit#

City *

State *

Zip *

If a patient representative would need to contact you regarding the information you provided, what is your preferred contact information:
Preferred Contact Phone Number*	Home Work Cell Other
Time of Day

Home Phone *

Work Phone

Cell Phone

Special Instructions

Guarantor Information (Person responsible for the bill)

Same as Patient *

Yes No

First Name *
Middle Initial
Last Name *
Residence Same as Patient *	Yes No
Date Of Birth*

Street Address *
Apt/Unit#
City *
State *
Zip *
Home Phone *
Work Phone
Cell Phone

* required field

Hours:

Monday through Friday:
8 a.m. to 4:30 p.m.

Upon Your Arrival at WestHealth:

We are required by State and Federal law to obtain your authorization for:

Consent for services
Assignment of benefits
Acknowledgement of your receipt of our
Notice of Privacy

You will be asked for a picture ID and current insurance information each time you check in for an appointment. Please alert us to any changes in insurance or personal information.

We appreciate your assistance in helping us maintain accurate and up-to-date information for your medical chart and billing records. This helps assure the timely processing of your insurance claims and medical records.

Coverage
Is this service related to an injury? *	Yes No
No Insurance - Private Pay *	Yes No