New Patient Enrollment

Please complete all sections below. All information is encrypted and stored securely in accordance with HIPAA guidelines.

DemographicsInsuranceLegal RepresentativeConsentsPhysician & Emergency Contact

Step 1 of 5: Demographics

Patient Demographics

Please provide the patient's full legal name for demographic records. All fields marked with * are required.

First Name *

M.I.

Last Name *

Date of Birth *

Social Security #

Gender

MaleFemaleOther

Facility Name

Facility Phone #

City

State

Building Name / Number

Patient Room / Apt / Unit #

Patient Personal Cell or Direct Phone (if applicable)

Marital Status

MarriedDivorcedWidowedPartneredSingle

Race / Ethnicity (select all that apply)

American Indian/Alaska NativeAsianBlack/African-AmericanHispanic/LatinoNative Hawaiian/Other Pacific IslanderWhiteDecline to answerUnknown

Primary Language

Country of Origin

Interpreter Needed?

Drug Allergies

Confirmation Email

We'll send a confirmation to this address once your enrollment is submitted. This is typically the family member or caregiver completing the form.

Your Email Address *

Your Relationship to Patient

Questions? Call us at (262) 235-3115 (Eastern WI) or (715) 201-2233 (Western WI) — available 24/7/365.

We're Here When You're Ready

Whether you have questions, need support, or are exploring care options — our team is here to guide you at your pace.

A rapidly growing, multi-service healthcare organization delivering high-quality care directly to patients across Wisconsin.