Patient Pre-Registration

Pre-Register for your test or procedure

Welcome to Valley View Hospital's online Pre-Registration. If you have a test or procedure scheduled, please fill out the following form in its entirety. Please note that fields marked with an asterisk (**) are required to be filled in. This form will not submit if one of these fields is left blank. If the question for a required field does not apply to your situation, please enter “NA" or "Not Applicable".
Please fill in as many fields as possible - the more questions you answer for us, the better we are able to serve you.

If you have questions about the online pre-registration process or would prefer to pre-register by telephone, please call 970.945.6535.

All information submitted in this Pre-registration site is maintained as confidential and secure.

Valley View Hospital respects your private and personal health information. We maintain confidentiality and security as required by Federal HIPAA Guidelines. Our staff is skillfully trained to secure and keep your personal health information private. Please contact the Privacy Office at 970-384-6810 if you have any concerns about your privacy.

Please Note: Online pre-registrations are checked Monday-Friday, 8 a.m. to 4:30 p.m. Please allow at least one full business day before your appointment for your pre-registration form to be processed. If there is less than one full business day before your appointment, please pre-register by calling 970.945.6535.

Move forward to any field by clicking with your mouse or using your Tab key.

Patient Information

 Yes No

-----------------------------Employment Information---------------------------

-----------------------------------Guarantor Information-----------------------------------

The guarantor is the person who is guaranteeing payment (usually the same as the patient if the patient is over age 18).

NOTE: If patient is guarantor skip this section

 Yes No

-------------------------------------- Policy Information---------------------------------------

 Yes No

Please bring your insurance card with you to your appointment so that we can make a copy of it.

 Yes No

------------------------------------------Secondary Insurance-------------------------------

 Yes No

Please bring your insurance card with you to your appointment so that we can make a copy of it.

 Yes No

--------------------------------Emergency Contact Information--------------------------

----------------------------------- second emergency contact -----------------------------

----------------------------------- Just a few more questions -----------------------------

 Yes No

 Yes No