Pre-Registration


At Children's Hospitals and Clinics, we encourage patients who have an appointment for Surgery, Radiology (X-ray), or (Special Diagnostics - St. Paul location only) to pre-register for their appointment. This will expedite your check-in process. Pre-registration can be completed on-line, or by calling the Admitting Department whenever it's convenient for you.

Note: Please allow us enough time to update the patient's account with your pre-registration information by submitting on-line no later than 3:00 pm, the day before your service.

    Children's - Minneapolis: (612) 813-8957
    Children's - St. Paul: (651) 220-6933
    Children's - Minnetonka: (952) 930-8600

If you use Children's Medical Organizer (CMO), you can pre-register when you add the appointment. Existing CMO information automatically pulls into the form, so that you don't have to type it in. Find out more.

To complete the pre-registration process on this page, fill out the form below and click the "Submit" button.

  • 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.

After we have received your online pre-registration, it will be processed. You will only be contacted if there is any additional information needed to complete your pre-registration.

This site uses a secure server (SSL) to encrypt all of your personal information. We use strong security measures to protect and prevent the loss of your information.

* This field must be filled in before submitting your registration

Which campus is the patient visiting? *

Which department is the patient visiting? *

What date will the patient be arriving for services? *

Who will bring the patient for services?

                                                      

Patient Information
Legal First Name: *
Legal Last Name: *
Middle Name: *
Must check if No Middle Name
Preferred First Name: (nickname)
Date of Birth: (mm/dd/yyyy) *
Gender:*
Marital Status: *
Address: *
Apartment Number:
City:* State:* Zip:*
Home Phone with area code: (xxx-xxx-xxxx)*
Cell Phone with area code: (xxx-xxx-xxxx)
Call Instructions:
Race: *
Religion: *
Is an interpreter needed?:
Language Spoken in Home: *
What Country was the patient born in?: *
Surgeon's Name:
Primary Care Physician(Pediatrician or Family Doctor):
Primary Care Physician Phone with area code: (xxx-xxx-xxxx)
Primary Care Clinic Name: *
Primary Care Clinic Location: *
Guardian 1 Information (Must be a biological parent or have court appointed legal guardianship.)
Relationship to Patient: *
eMail Address
Legal First Name: *
Legal Last Name: *
Middle Name:
Date of Birth: (mm/dd/yyyy)*
Copy address info from:   Patient 
Address: *
Apartment Number:
City:* State:* Zip:*
Home Phone with area code: (xxx-xxx-xxxx)*
Cell Phone with area code: (xxx-xxx-xxxx)
Work Phone with area code: (xxx-xxx-xxxx)
Work Phone (Extension):
Call Instructions:
Guardian 2 Information (Must be a biological parent or have court appointed legal guardianship.)
Relationship to Patient:*
eMail Address
Legal First Name:*
Legal Last Name:*
Middle Name:
Date of Birth: (mm/dd/yyyy)*
Copy address info from:   Patient  Guardian 1 
Address:*
Apartment Number:
City:* State:* Zip:*
Home Phone with area code: (xxx-xxx-xxxx)
Cell Phone with area code: (xxx-xxx-xxxx)
Work Phone with area code: (xxx-xxx-xxxx)
Work Phone (Extension):
Call Instructions:
Emergency Contact Information (Who is the person that can contact Guardian 1 or Guardian 2 if we are unable to reach them?)
Relationship to Patient:
First Name:
Last Name:
Middle Name:
Home Phone with area code: (xxx-xxx-xxxx)
Cell Phone Number with area code: (xxx-xxx-xxxx)
Call Instructions:
Guarantor Information (Who is responsible for the bill?)
Copy same info from:   Patient  Guardian 1  Guardian 2 
Relationship to Patient: *
Legal First Name: *
Legal Last Name: *
Middle Name:
Date of Birth: (mm/dd/yyyy) *
Address: *
Apartment Number:
City:* State:* Zip:*
Home Phone with area code: (xxx-xxx-xxxx)*
Cell Phone with area code: (xxx-xxx-xxxx)
Work Phone with area code: (xxx-xxx-xxxx)
Work Phone (Extension):
Call Instructions:
Occurrence Information
Is this visit related to an accident or injury?
Occurrence Type: *
Occurrence Date:
(mm/dd/yyyy) *
Occurrence Time: (hh:mm) * AM PM
Occurrence Location: *
Occurrence Description: *
Primary Health Insurance Information (Who holds a health insurance policy for the patient?)
Copy same info from:   Patient  Guardian 1  Guardian 2 
Relationship to Patient: *
Legal First Name: *
Legal Last Name: *
Middle Name:
Date of Birth: (mm/dd/yyyy) *
Employment Status: *
Employer Name: *
Employer
City: State: Zip:
Insurance Company Name: *
Insurance Address Line One:
Insurance Address Line Two:
City: State: Zip:
Customer Service Phone with area code: (xxx-xxx-xxxx)
Group Number:
Policy Number/ID #:
Secondary Health Insurance Information (Who holds a health insurance policy for the patient?)
Copy same info from:   Patient  Guardian 1  Guardian 2 
Relationship to Patient:
Legal First Name:
Legal Last Name:
Middle Name:
Date of Birth: (mm/dd/yyyy)
Employment Status:
Employer Name:
Employer
City: State: Zip:
Insurance Company Name:
Insurance Address Line One:
Insurance Address Line Two:
City: State: Zip:
Customer Service Phone with area code: (xxx-xxx-xxxx)
Group Number:
Policy Number/ID #:
Additional Insurance Plans?