Patient Pre-Registration

PLEASE NOTE: If you have a condition that may be life-threatening or you have chest pain, profuse bleeding, severe breathing difficulty, traumatic injury, or have been in a major accident, call 9-1-1 or go directly to the nearest emergency room.

Welcome to Wheaton Franciscan Medical Group patient Pre-Registration Site! We have created this feature to make it easy for you to register with us via our secured web site because we understand how busy you are.

If you are a Medicare Patient with an appointment at a Racine Office you must Pre Register by phone. Please contact the Medical Group Pre Registration Unit at 262-687-7700

Pre-Registration Form

WFMG Provider:

Please select from the following list:

Please bring your co-pay to your appointment:
Co-pay Amount:

Please enter the date of your appointment *


Patient Information

Last Name*:

 

First Name*:

Full Middle Name:

Address*:

Date of Birth*:
  

City*:

Telephone*:
   

State*:    ZIP*:
 

Gender*:

Marital Status*:

Primary Language Spoken*:

Employer*:

Employment Status*:
 

Guarantor Information (person responsible for the bill)

Guarantor's Name: *

 

Guarantor's Date of Birth*:
  

Relationship to Patient: *

Guarantor's Employer:*

Guarantor's Address:*

Employer's Address: *

Guarantor's City:*

Employer's City:*

Guarantor's State:*     ZIP:*
 

Employer's State: *       ZIP:*
 
 

Injury/Illness Information

Is this visit or procedure covered by Workman's Compensation?
 Yes     No

Is the illness or injury due to a non-work accident?
 Yes     No

If this illness or injury is due to a non-work related accident, please describe below. Please include where, when and how the injury occurred:
 

Primary Insurance Information

Primary Insurance Company Name:*

Effective Date:

Type of Insurance (refer to logo on card, if applicable):*
 AH     AHC     HCN     HEOS     HMO  MEI     PPO     WPPN   

Is the patient the policy holder?*
 Yes     No

 

If not, policy holder name:

Relationship to Patient:*

Policy Holder's Date of Birth:
  

Group/Employer Name:*

Insurance Co. Address:

ID/Policy/Subscriber #:*

Insurance Co. City:

Group Number:*

Insurance Co. State: ZIP:
 
 

Secondary Insurance Information

Secondary Insurance Company Name:

Effective Date:

Type of Insurance (refer to logo on card, if applicable):
 AH     AHC     HCN     HEOS     HMO  MEI     PPO     WPPN   

Is the patient the policy holder?
 Yes     No

 

If not, policy holder name:

Relationship to Patient:

Policy Holder's Date of Birth:
  

Group/Employer Name:

Insurance Co. Address:

ID/Policy/Subscriber #:

Insurance Co. City:

Group Number:

Insurance Co. State: ZIP:
 
 

Emergency Contact Information

1st Emergency Contact Name:

 

Relationship to Patient:

Address:

City:

 

State:    ZIP:
 

Telephone:
   

2nd Emergency Contact Name:

 

Relationship to Patient:

Address:

City:

 

State:    ZIP:
 

Telephone:
   

 


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