Before your visit, please complete a pre-registration form. You can either fill out the form below or call HealthEast Pre-Registration at 651-232-5855. We also suggest that you consult your insurance company to determine your benefits and any pre-authorization or referral requirements.
Patient information
Reason for visit
 
Legal first name*
 
Preferred name
 
Middle initial Enter N/A if you do not have one.*
 
Last name*
 
Maiden name
 
E-mail address
 
Sex*
Male
Female
 
Birth date*
 
Marital status*
 
Social Security Number
 
Address*
 
Apartment number
 
City*
 
State*
 
Zip code*
 
Best phone number*
 
Type of phone*
 
Alternate phone number
 
Type of phone*
 
Alternate phone number
 
Type of phone*
 
Do you need an interpreter?
Yes
No
 
If yes, language preference
 
Is the patient currently employed? *
Yes
No
Retired
 
Type of employment
Full Time
Part Time
 
Employer
 
Employer’s phone
 
Employer’s address
 
Primary doctor's first name
 
Primary doctor's last name*
 
Primary doctor's clinic & location Enter "No primary" if you do not have a primary care clinic.*
 
We review all patients' treatment to ensure that everyone receives the highest quality of care. To help with our review, can you please provide your race, country of origin and religion.
 
 
What race best describes you? *
 
In what country were you born?
 
What religion do you practice?
 
Would you like us to notify a church of your inpatient stay?*
Yes
No
 
Guarantor information
If you are under the age of 18 and not an emancipated adult, you cannot list yourself as guarantor. However if you are under the age of 18 and pregnant you can list yourself as guarantor. Guarantor (person responsible for the bill)*
Self
Other
 
Visit information
Is this visit due to an injury?*
Yes
No
 
What was the cause of your injury?*
 
What type of insurance will you be using for this visit?*
 
Patient representative and alternate contact
If at any time you are unable to speak for yourself during or following your procedure, who would you like to list as a contact to involve in your care planning?
 
 
Name of patient representative (first last)*
 
Relationship*
 
Main phone*
 
Alternative phone
 
Is this person able to make medical decisions for you?
Yes
No
 
Alternate contact*
Same as above
Other