At Children's Minnesota, we encourage Patients & Families to complete a registration on-line.
You can always call Main Patient Registration's PreRegistration line with questions or to complete a preregistration by phone 612-813-7900
General visit information
Which campus is the patient visiting? *
- Click to Select -
Minneapolis
St. Paul
Children's Minnetonka
Which department is the patient visiting? *
Who will bring the patient for services? *
- Click to Select -
Aunt
Brother
County Social Services
Cousin
Employee
Father
Foster Father
Foster Mother
Friend of the Family
Grandfather
Grandmother
Guardian
Life Partner
Mother
Self/Patient
Sister
Spouse
Step Father
Step Mother
Uncle
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.
General Patient Information
Gender *
- Click to Select -
Female
Male
Unknown
Marital Status *
Single
Divorced
Legally Separated
Life Partner
Married
Unknown
Widowed
Patient Contact Information
Preferred Reminder Type *
- Click to Select -
Cell Text
Cell Voice
Home
PATIENT DEMOGRAHIC INFORMATION
At Children's, what language would you like the staff to use to communicate about your child's care? *
- Click to Select -
Decline
Acholi
Afar
Akan
Amharic
Anuak
Arabic
Bassa
Bengali
Berber
Bosnian
Burmese
Cambodian (Khmer)
Cantonese
Cebuano
Chin
Chuukese
Creole
Croatian
Dutch
English
Ewe
Farsi
French
Fulani
Gbandi
German
Gio
Gujarati
Gwi
Hebrew
Hindi
Hmong
Igbo
Indonesian
Italian
Japanese
Karen
Karenni
Korean
Kpelle
Krahn
Krio
Kurdish
Kutchi
Laotian
Liberian
Lingala
Lisu
Ma'di
Malayalam
Mam
Mandarin
Mandingo
Marathi
Marshalese
Moldovan
Mon
Nepali
None
Nuer
Oromo
Pastho
Polish
Portuguese
Punjabi
Quechua
Quiché
Romanian
Russian
Serbian
Sign Language - ASL
Sign Language - Tactile
Singhalese
Somali
Spanish
Swahili
Tagalog
Tamil
Tausug
Telugu
Thai
Tibetan
Tigrigna
Turkish
Ukranian
Urdu
Urhobo
Vai
Vietnamese
Yoruba
Zande
Other
Unknown
Is an interpreter needed? *
- Click to Select -
No
Verbal
Tactile
Sign
How do you identify your child's race? *
- Click to Select -
African
American Indian/Alaskan Native
Asian
Black/African American
Declined
Hispanic/Latino
Middle Eastern
Native Hawaiian/Pacific Islander
Unknown
White/Caucasian
Is there a religious preference for your child? *
- Click to Select -
Chose not to disclose/decline
Christian
Christian Missionary Alliance
Christian Scientist
Church of God
Church of Jesus Christ(LDS/Mormon)
Church of the Brethen
Congregational
Covenant
Disciples of Christ
Eastern Orthodox
Episcopal
Evangelical Free
Greek Orthodox
Hindu
Humanist
Jehovah's Witness
Jewish - Conservative
Jewish - Orthodox
Jewish - Reformed
Lutheran
Lutheran - ELCA
Lutheran - Missouri Synod
Lutheran - WELS
Mennonite
Methodist
Muslim
Non Denominational
None
Orthodox
Other
Pentecostal
Presbyterian
Quaker
Reformed Church of America
Reformed Church of Latter Day Saints
Russian Orthodox
Salvation Army
Scientology
Seventh Day Adventist
Shamanism
Sikh
Southern Baptist
Spiritual
Country of birth *
PATIENT PRIMARY CARE INFORMATION
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
- Click to Select -
Aunt
Brother
Father
Grandfather
Grandmother
Guardian
Mother
Self/Patient
Sister
Step Father
Step Mother
Uncle
GUARDIAN #1 CONTACT INFORMATION
Preferred reminder type *
- Click to Select -
Cell Text
Cell Voice
Home
GUARDIAN #2 INFORMATION - (Must be a legal or court appointed guardian.)
Relationship to patient *
- Click to Select -
Aunt
Brother
Father
Grandfather
Grandmother
Guardian
Mother
Self/Patient
Sister
Step Father
Step Mother
Uncle
GUARDIAN #2 CONTACT INFORMATION
Preferred reminder type
- Click to Select -
Cell Text
Cell Voice
Home
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
- Click to Select -
Patient
Guardian 1
Guardian 2
Relationship to Patient *
- Click to Select -
Aunt
Brother
County Social Services
Cousin
Employee
Father
Foster Father
Foster Mother
Friend of the Family
Grandfather
Grandmother
Guardian
Life Partner
Mother
Self/Patient
Sister
Spouse
Step Father
Step Mother
Uncle
OCCURRENCE INFORMATION
PRIMARY HEALTH INSURANCE (Who holds a health insurance policy for the patient?)
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.