BMC - Online Registration

You may also download this form (requires Acrobat) , print it out and bring it in with you. If you are already a registered patient you don't need to fill out this form, you may request an appointment instead.

If this is an emergency don't use this page, please call the clinic at: 218-828-2880 or toll free at: 800-277-8262

YOUR INFORMATION
Your Name:
Date of Birth:
Social Security Number:
Home Phone Number:
Your Address:
Cell Phone Number:
Address Line Two:
Work Phone Number:
City:
Email Address:
State:
    
Zip Code:
    
Employer Name:
Employer Address:
   
INSURANCE INFORMATION
Insurance Company :
Insurance Policy Number:
SPOUSE INFORMATION
Spouse Name:
Date of Birth:
Social Security Number:
Work Phone Number:
Employer Address:
   
Employer Address Line Two:
   
CHILD INFORMATION - List all children
 
In case of an emergency (other than home)
Name:      Phone Number:
Relationship to Patient:
    

 

 
Appointments: 218-828-2880 · 800-277-8262 | Other: 218-828-7100 · 800-677-8262 | Business Office: 218-828-7110 | Fax: 218-828-7107
Brainerd Medical Center, Inc. 2024 South Sixth Street · Brainerd, MN 56401      ©2007 Brainerd Medical Center - Privacy and Refund Policy