Children’s Pre-Registration

General Patient Information

Legal First Name *

Preferred First Name / Nickname

Legal Last Name *

Legal Middle Name *

No Patient Middle Name?

Check if No Middle Name

Date of Birth *

(MMDDYYYY)

Gender *

Marital Status *

Patient Contact Information

Patient Address *

Apartment #

City *

State *

Zip *

Home Phone *

Include Area Code

Mobile Phone

Include Area Code

Call Instructions

PATIENT DEMOGRAHIC INFORMATION

At Children's, what language would you like the staff to use to communicate about your child's care? *

Is an interpreter needed? *

How do you identify your child's race? *

Is there a religious preference for your child? *

Country of birth *

PATIENT PRIMARY CARE INFORMATION

Primary care physician (pediatrician or family doctor)

Primary care clinic name *

Primary care clinic location *

Surgeon

Please make certain all required fields (indicated by a *) are completed. Fill in as many fields as possible so we can best prepare your registration.

To process your insurance submissions accurately in a timely manner, it is necessary to have both parents full legal names which includes a middle name and their date of birth.

Step-parents are not considered a legal guardian without proper documentation.

GUARDIAN #1 INFORMATION - (Must be a legal or court appointed guardian.)

Relationship to patient

Legal first name *

Legal last name *

Legal middle name

Date of birth (MMDDYYYY) *

GUARDIAN #1 CONTACT INFORMATION

My contact information is the same as the patient's.

Address *

Apartment #

City *

State *

Zip *

Home phone *

Include area code

Cell phone

Include area code

Work phone

Include area code

Work phone extension

Call instructions

GUARDIAN #2 INFORMATION - (Must be a legal or court appointed guardian.)

Check this box if No second guardian

Relationship to patient *

Legal first name *

Legal last name *

Legal middle name

Date of birth (MMDDYYYY) *

GUARDIAN #2 CONTACT INFORMATION

My contact information is the same as the patient's.

Address *

Apartment #

City *

State *

Zip *

Home phone *

Include area code

Cell phone

Include area code

Work phone

Include area code

Work phone extension

Call instructions

Please make certain all required fields (indicated by a *) are completed. Fill in as many fields as possible so we can best prepare your registration.

EMERGENCY CONTACT - (Person we can contact if guardian(s) cannot be reached.)

Relationship to patient

First name

Last name

Middle name

Home phone with area code

Cell phone with area code

Call Instructions

Please make certain all required fields (indicated by a *) are completed. Fill in as many fields as possible so we can best prepare your registration.

GUARANTOR INFORMATION - (Who is responsible for the bill?)

Copy information from

Relationship to Patient *

Legal first name *

Legal last name *

Middle name

Date of birth *

Address *

Apartment #

City *

State *

Zip *

Home phone *

Include area code

Cell phone

Include area code

Work phone

Include area code

Work phone extension

Call Instructions

OCCURRENCE INFORMATION

Check this box if this visit is related to an accident or injury

PRIMARY HEALTH INSURANCE (Who holds a health insurance policy for the patient?)

Check this box for Self Pay (no insurance)

The Financial Resources Department can be reached at:
Children's - Minneapolis: 612-813-6432
Children's - St. Paul: 651-220-6367

Policy Holder

Employer Information

Copy information from:

Employer name *

Relationship to patient: *

Employer city

Legal first name *

Employer state

Legal last name *

Employer zip

Middle name

Date of birth (MMDDYYYY) *

Employment status *

Insurance Company

Name *

Customer service phone w/ area code *

Address line 1

Group number (important)

Address line 2

Policy number/ID number (important)

City

State

Zip

SECONDARY HEALTH INSURANCE (Who holds a health insurance policy for the patient?)

Policy Holder

Employer Information

Copy information from:

Name

Relationship to patient:

City

Legal first name

State

Legal last name

Zip

Middle name

Date of birth (MMDDYYYY)

Employment status

Insurance Company

Name

Customer service phone w/ area code

Address line 1

Group number

Address line 2

Policy number/ID number

City

State

Zip

Additional Insurance Plans?

Please make certain all required fields (indicated by a *) are completed. Fill in as many fields as possible so we can best prepare your registration.

Your pre-registration is not complete until you click the Submit button at the bottom.

VISIT INFORMATION

Campus:
Department:
Date of service:
Who will bring patient:

PATIENT INFORMATION

Legal first name:
Legal middle name:
Legal last name:
Preferred first name/nickname:
Date of birth:
Gender:
Marital status:

Address:
Apartment #:
City:
State:
Zip:
Home phone:
Cell phone:
Call instructions:

Language spoken in home:
Interpreter needed:	No
Race:
Religion:
Country of birth:

Primary care physician:
Primary care clinic:
Primary care clinic location:
Surgeon:

GUARDIAN INFORMATION

Relationship to patient:
Legal first name:
Legal middle name:
Legal last name:
Date of birth:
Address:
Apartment #:
City:
State:
Zip:
Home phone:
Cell phone:
Work phone:
Work phone extension:
Call instructions:

No second guardian?
Relationship to patient:
Legal first name:
Legal middle name:
Legal last name:
Date of birth:
Address:
Apartment #:
City:
State:
Zip:
Home phone:
Cell phone:
Work phone:
Work phone extension:
Call instructions:

EMERGENCY CONTACT

Relationship to patient:
First name:
Middle name:
Last name:
Home phone:
Cell phone:
Call instructions:

INSURANCE INFORMATION

Relationship to patient:
Legal first name:
Middle name:
Legal last name:
Date of birth:
Address:
Apartment #:
City:
State:
Zip:
Home phone:
Cell phone:
Work phone:
Work phone extension:
Call instructions:

Is this visit related to an accident or injury?	No
Occurrence type:
Occurrence date:
Occurrence time:
Occurrence location:
Occurrence description:

Self Pay?	No
Relationship to patient:
Legal first name:
Middle name:
Legal last name:
Date of birth:
Employment status:
Employer name:
Employer city:
Employer State:
Employer Zip:
Insurance company name:
Insurance address line one:
Insurance address line two:
Insurance company city:
Insurance company state:
Insurance company zip:
Customer service phone:
Group number:
Policy number/ID number:

Relationship to patient:
Legal first name:
Middle name:
Legal last name:
Date of birth:
Employment status:
Employer name:
Employer city:
Employer State:
Employer Zip:
Insurance company name:
Insurance address line one:
Insurance address line two:
Insurance company city:
Insurance company state:
Insurance company zip:
Customer service phone:
Group number:
Policy number/ID number:
Additional Insurance Plans?	No

Children’s Pre-Registration

General visit information

General Patient Information

Patient Contact Information

PATIENT DEMOGRAHIC INFORMATION

PATIENT PRIMARY CARE INFORMATION

GUARDIAN #1 INFORMATION - (Must be a legal or court appointed guardian.)

GUARDIAN #1 CONTACT INFORMATION

Mobile Phone Consent Agreement

I understand and accept each of the following:

GUARDIAN #2 INFORMATION - (Must be a legal or court appointed guardian.)

GUARDIAN #2 CONTACT INFORMATION

Mobile Phone Consent Agreement

I understand and accept each of the following:

EMERGENCY CONTACT - (Person we can contact if guardian(s) cannot be reached.)

GUARANTOR INFORMATION - (Who is responsible for the bill?)

OCCURRENCE INFORMATION

PRIMARY HEALTH INSURANCE (Who holds a health insurance policy for the patient?)

Policy Holder

Employer Information

Insurance Company

SECONDARY HEALTH INSURANCE (Who holds a health insurance policy for the patient?)

Policy Holder

Employer Information

Insurance Company

Your pre-registration is not complete until you click the Submit button at the bottom.

VISIT INFORMATION

PATIENT INFORMATION

GUARDIAN INFORMATION

EMERGENCY CONTACT

INSURANCE INFORMATION

Request an appointment

Refer a patient

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