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Patient pre-registration is an easy, time-saving service that allows you to pre-register for many medical services at your convenience. Your paperwork is already filled out when you arrive for your appointment. Forms can be accessed and printed here.

If you have any problems completing your pre-registration, call us and we will help you through the process. We're available Monday – Friday, 7 a.m. – 6 p.m., at 800-807-7667

What You Need to Pre-Register

  • Your insurance ID card
  • Social Security number and date of birth of the insurance cardholder
  • Procedure date and time
  • Type of procedure (such as a mammogram or X-ray)
  • Personal contact information
  • Your doctor’s order

Before Your Procedure

Fax your completed form to 419-221-6148 at least 24 hours before your appointment. Bring the form, your doctor's order and your insurance card on the day of your procedure. Depending on your procedure, your form may list other items you should bring to your appointment.

You will need Adobe® Acrobat® Reader to view PDF documents. Download a free copy from the Adobe Web site.