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  Pre-register for your visit to Buffalo Hospital

At Buffalo Hospital, we encourage all patients to pre-register for scheduled services to ensure a quicker check-in process. Please pre-register at least two business days prior to your appointment. If your appointment is less than one business day away or you would like to pre-register by telephone, please call 763-684-3800.

To preregister online simply fill out the form below.

  • Make sure all the required fields noted with an asterisks (*) are completed before submitting your registration.
  • Please bring your insurance card with you.

This site uses a secure server to encrypt all your personal information and protect your confidentiality and privacy. See our Privacy Policy.

Thank you for choosing Buffalo Hospital.

* 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?  
 
Patient Information
  Legal Name
*    Last:  
*    First:  
     Middle:  
  Social Security Number: - -  
  Marital Status: Single Separated Divorced
Widowed Married Life Partner		  
* Sex: Male Female
  Race: (Required for Government reporting and medical research) African American Asian Hispanic
American Indian Caucasian Other		  
* Date of Birt:h Month Day Year  
Mailing Address
* Street:  
* City:  
*State:  
* Zip:  
  County:  
* Phone Number:  
* Employment Status: Full-Time Not Employed Student
Part-Time Self-Employed Retired		  
  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:  
  Sex: Male Female  
  Date of Birth: Month Day Year  
  Social Security Number:  
  Marital Status: Single Widowed Separated
Married Divorced Life Partner		  
  Guarantor Mailing Address  
  Street:  
  City:  
  State:  
  Zip:  
  County:  
  Employment Status: Full-Time Not Employed Student
Part-Time Self-Employed Retired		  
  Employer:  
  Work Phone:  
  Employer Address [City , State, Zip]:  
    
Spouse Information
  Spouse Name:  
     Last:  
    First:  
    Middle:  
 Date of Birth: Month Day Year  
 Social Security Number:  
 Employment Status: Full Time Not Employed Retired
Part Time Self Employed Student		  
  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]
 Type of Accident: Work Related Crime Victim
Auto Accident Other		  
  Date of Accident: Month Day Year  
  Place of Accident/Injury:  
  Nature of Accident:  
 
Insurance Information - Primary
  Name of Insurance Company:  
  Policy Holder Name:  
  Relationship to Patient:  
  Group/Account Number:  
  Policy/ID Number/Claim Number:  
 
Insurance Information
  Do you have Medicare: Yes No  
  Effective Dates: Part A
Part B 		 
  Are you entitled to Medicare based on: Age Disability End Stage Renal Disease  
  Do you receive black lung medical benefits? Yes No  
  Will your services be paid by government program other than Medicare/Medicaid? Yes No  
        If yes, please
     explain 		 
 
Secondary Insurance Information
  Name of Insurance Company:  
  Policy Holder Name:  
  Relationship to Patient:  
  Group/Account Number:
  Policy/ID Number:  
  Eligibility /Benefit /Customer Service Number:  
  Insurance Company Address:  
  Additional Information:  



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.

 

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