Avera McKennan
Pre-Admission Center
Online Patient Registration

If you have any questions concerning the completion of this form, please call (605) 322-8100 Monday - Thursday, 8 AM - 7 PM or Friday, 8 AM - 4:30 PM. You must pre-register online one full business day (24 hours) prior to services.

Please use your TAB key to move from one question to the next. If you press ENTER, it will submit your form, and your information will not be complete. After you have completed the entire form, please click on the SUBMIT button below.  Thank You!
* Note: For the purpose of proper identification, these fields are required.

Please complete the entire form completely and accurately.

 Please remember to bring your insurance card(s) and driver's license with you on the day of your procedure.


Please indicate either:
- The date you are coming to the hospital for admission/testing.
- Your due-date if your appointment is maternity/OB related.

*   Format: mm/dd/yy   

Time you were instructed to be at the hospital Maternity/OB patients please enter "OB"

*

Phone Number where we can reach you the night before your surgery or appointment
*


Patient Information
Last Name *

First Name *

Middle Initial
E-mail Address
Social Security Number *
Birth Date (mm/dd/yy) *

Previous Avera McKennan Patient?

Previous Admission Name (first, middle last)
Gender 
Street Address 
City 
State                       Zip Code  
Phone Number     XXX-XXX-XXXX
Marital Status
Race              
Religion            
Name of Church
EMPLOYER Information
Employer     
City              
State                   Zip Code  
Phone            XXX-XXX-XXXX
Emergency Contact Information
Contact Person (full name)
 (next of kin to be notified in case of an emergency)
Relationship to you  
Address     
City            
State                 Zip Code   
Home Phone     XXX-XXX-XXXX
Work Phone      XXX-XXX-XXXX
Person to Notify(full name)
  (additional contact in case of an emergency)
Relationship to You 
Address 
City        
State              Zip Code 
Home Phone     XXX-XXX-XXXX
Work Phone      XXX-XXX-XXXX
Guarantor
(the person who is responsible for the bill after insurance pays)
If "Self," skip to INSURANCE INFORMATION.
 If "Other Person," complete the following:
Guarantor's
Full Name    
Address        
City              
State                 Zip Code 
Home Phone     XXX-XXX-XXXX
Work Phone      XXX-XXX-XXXX
Social Security #            
Relationship toPatient   
Employer 
Employer's Address  
City     
State         Zip Code 
Employer's Phone   XXX-XXX-XXXX
Insurance Information
Primary Insurance
Name of Primary Insurance Company(e.g. Medicare, Wellmark, etc.)
Address
City   
State       Zip Code 
Insurance Co. Phone   XXX-XXX-XXXX
Policy Number                     
Policy Holder Full Name (as it appears on insurance card)
Policy Holder Date of Birth

Relationship to Patient
Group Name      
Group Number   
Secondary Insurance
Name of Secondary Insurance Company (e.g. Medicare, Wellmark, etc.)
Address
City    
State       Zip Code  
Insurance Co. Phone   XXX-XXX-XXXX
Policy Number     
Policy Holder Full Name (as it appears on insurance card)
 
Policy Holder Date of Birth 
Relationship to Patient      
Group Name
Group Number 
MEDICARE INFORMATION
If covered by Medicare, please complete the following questions.

If not covered by Medicare, skip this section and continue to the
"Additional Patient Information" section.
Did you receive Medicare because of:
Do you have insurance through any employer?   
Your retirement date (mm/dd/yy): 

Spouse's retirement date (mm/dd/yy):
Are you currently enrolled in a Medicare HMO?
Is your illness/injury work related?  
Is your illness/injury covered by the Black Lung program?
Has the VA authorized/agreed to pay for this visit?
Is the illness/injury due to:  
Have you been hospitalized as an inpatient or outpatient in the last three days?  
Are you coming from a nursing home?  

ADDITIONAL PATIENT INFORMATION
If you have any known allergies, please list them here. If you are not aware of any allergies, please type NKA:
Are you a veteran?
Advanced Directives (please answer if the following apply to you: inpatient or home care, age 18 and older)

Do you have an advance directive that specifies your healthcare wishes in the event you are unable to tell us? If yes, please bring a copy with you. 

Primary Care Physician/Family Doctor
Attending Physician (full name) - this is the physician requesting service for you
Family Physician (full name)
Referring Physician (full name)
May we send records to:

  

Please remember to bring your insurance card(s) and driver's license with you on the day of your procedure.
If you have checked the above information for accuracy, please click on the submit button to send your form. Thank you!