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Preregister for your visit to Mercy Hospital

At Mercy Hospital, we encourage all patients to preregister. This way, your paperwork can be prepared before you arrive and we can expedite your check-in process.

To preregister for a test or procedure scheduled at Mercy Hospital, please fill out the form below.

  • Make sure all required fields (*) are filled in.
  • If a required field does not apply to you, type in "NA" or "Not Applicable."
  • Fill in as many fields as possible so we can best prepare your registration.

If you have questions or would like to preregister by telephone, please call 612-262-5335.

Please note: Online preregistrations are entered Monday to Friday, 8 a.m. to 4:30 p.m. Please preregister at least one full business day before your appointment.

If your appointment is less than one full business day away, preregister by phone. Please call 612-262-5335.

Allina Hospitals & Clinics is committed to maintaining an organization-wide tobacco-free environment. The use of tobacco products is prohibited on all Allina owned and leased premises. Please remember to leave your valuables at home (jewelry, cash, etc.)

* indicates required field

 
* What date will you be arriving for services? Month Day Year (or due date)  
  Personal Physician or Family Physician Name Last
First 		 
* What procedure/test are you having done?  
     
  Email address to receive confirmation  
 
Patient Information
  Legal Name
*    Last  
*    First  
     Middle Initial  
  Social Security Number - -  
  Marital Status  
* Sex
  Race (Required for Government reporting and medical research)
 
* Primary Language Spoken in the Home  
  Religion  
* Date of Birth Month Day Year  
Mailing Address
* Street  
* City  
*State  
* Zip  
  County  
* Day Phone  
* Evening Phone  
* Employment Status
 
  Retirement Date  
  Employer  
  Occupation  
  Work Phone  
  Employer Address [City , State, Zip]  
 
Guarantor Information
[Person responsible for the bill. If the patient is the guarantor skip this section and go to Spouse Information]
Relation to Patient  
Guarantor Name
     Last  
     First  
     Middle Initial  
  Sex  
  Date of Birth Month Day Year  
  Social Security Number  
  Marital Status
 
  Guarantor Mailing Address  
  Street  
  City  
  State  
  Zip  
  County  
  Employment Status
 
  Guarantor's Retirement Date Month Day Year  
  Occupation  
  Work Phone  
  Employer Address [City , State, Zip]  
    
  Spouse Information
  Spouse Name  
     Last  
    First  
    Middle Initial  
 Date of Birth Month Day Year  
 Social Security Number  
 Employment Status
 
 Occupation  
  Employer  
  Work Phone  
 Employer Address [City , State, Zip]  
    
Emergency Contact Information (Other than listed above)
 Emergency Contact Name Last
First 		 
  Relation to Patient  
 Day Phone  
 Evening Phone  
 
Accident Information
[To be filled out if this visit/admission is the result of an accident]
* Is this visit related to an accident or injury?  
 Type of Accident
 
  Date of Accident: Month Day Year  
  Location of Accident/Injury  
 
Describe Accident 		 
 
Insurance Information
  Medicaid Patients  
* Do you have Medicaid?  
  Medicaid number  
  Do you have Medicare  
  Medicare Claim Number  
  Effective Dates Part A
Part B 		 
  Are you entitled to Medicare based on  
  Do you receive black lung medical benefits?  
  Will your services be paid by government program other than Medicare/Medicaid?  
        If yes, please
     explain 		 
 
  Insurance Information - Primary
  Name of Insurance Company  
  Policy Holder Name  
  Relationship to Patient  
  Group/Account Number  
  Policy/ID Number  
  Eligibility/Benefits/Customer Service Phone Number  
  Insurance Company Address  
 
 Secondary Insurance Information
  Name of Insurance Company  
  Policy Holder Name  
  Relationship to Patient  
  Group/Account Number
  Policy/ID Number  
  Eligibility /Benefit /Customer Service Phone Number  
  Insurance Company Address  
 
Other Information:
  Additional Information  
  Are you allergic to any medications?  
  Do you want the hospital to let people know that you are a patient here if friends call?  
  What name would you like the staff to call you?  
After we have received your online pre-registration, someone from pre-registration may contact you to confirm your registration.


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