Online Pre-Registration & Admission

In an effort to provide our patients with excellent service, we provide several ways for you to pre-register for an upcoming procedure, test or inpatient admission.

  • You may submit this online form up to 7-10 days prior to your scheduled test, procedure or inpatient admission. For your privacy, all information will be sent over a secure connection.
  • Or, you may print this form, fill it out and fax it to Patient Admission & Registration at (269) 226-5745 up to 7-10 days prior to your scheduled visit.

If you have any questions regarding this form, please contact Patient Admission & Registration at 1-800-682-8474. Pre-registration options for Borgess services also include:

  • Telephone registration at 1-800-682-8474 from 8 a.m. to 4:30 p.m., Monday through Friday
  • Walk-in on-site registration at Borgess Medical Center from 7 a.m. to 6 p.m., Monday through Friday.

Please follow any instructions you may have received from your physician regarding your arrival time, as well as any restrictions regarding eating and drinking. Please remember to bring the following:

  • A list of questions for the doctor or nurse
  • Any paperwork your physician has given you
  • Any authorization forms from your insurance provider
  • Your insurance card or Medicare/Medicaid cards

Social Security Number--
Date of Birth / /
Last Name
First Name
Middle Name
Street Address
City
State
Zipcode
Daytime Telephone -
Home Telephone -
eMail Address
Select Race
Select Marital Status
Religion Preference
Name of Family Physician
List any food allergies you have
List any allergies to medications you may have
List any other allergies you may have
Are you allergic to latex or latex products?
Relative & Emergency Contact Information
Name of nearest relative
Street Address of Relative
City
State
Zipcode
Home Telephone of Relative -
Work Telephone of Relative -
What is your relationship to this relative?
Name of Emergency Contact (someone other than nearest relative or spouse)
Daytime Telephone of Emergency Contact -
Work Telephone of Emergency Contact -
What is your relationship to the Emergency Contact?
Employer Information
Name of Employer
Street Address
City
State
Zipcode
Telephone -
Insurance Information
Primary Insurance
Name of cardholder
Cardholder ID / Member ID
Cardholder's Date of Birth / /
Cardholder Social Security Number--
Cardholder relationship to patient (self, spouse, parent, etc.)
Plan Number (If Medicare, type "A" or "B")
Group Number (If Medicare, type "Medicare")
Effective Date of Coverage / /
Primary Insurance Company Address
City
State
Zipcode
Precertification Telephone -
Is your insurance through your employer?
Secondary Insurance Information
Secondary Insurance Name
Name of Cardholder
Cardholder ID / Member ID
Cardholder Social Security Number--
Relationship of cardholder to patient
Plan Number (If Medicare, type "A" or "B")
Group Number (If Medicare, type "Medicare")
Effective Date of Coverage / /
Address of Secondary Insurance Company
City
State
Zipcode
Precertification Telephone -
Procedure / Test Information
Name of Admitting Physician (Physician ordering test or performing procedure)
Name of procedure / test
Date of Procedure / Test / /
Do you have an Advanced Directive, Power of Attorney or Living Will regarding your medical wishes?
Are you enrolled under a Medicare Hospice Program?
Is the procedure or test related to a hospice condition?
Is the procedure or test you are registering for a result of a work-related injury that may be convered under Worker's Compensation or Black Lung Disease?
Will the Department of Veterans Affairs (DVA) be authorizing and paying for services rendered?
Are services to be paid for by a government entity, such as a research grant?
After you submit this form, please be patient and wait for the confirmation screen. If you move to another site or close your browser before receiving the confirmation page, your pre-registration information will not be received by our staff. Thank you for your patience.