Mammography Pre-Registration

Welcome to Middlesex Health's Online Pre-Registration for Screening Mammogram Appointments

As a convenience for our patients, Middlesex Health offers online pre-registration for patients who have scheduled a mammogram.

Pre-registering for an upcoming screening mammogram appointment allows you to go directly to the appointment location. Your registration paperwork will be completed and waiting for you when you arrive.

In order to pre-register successfully, you must have a scheduled mammogram appointment. If you do not have an appointment and have a physician order for a mammogram, please call 860-358-2600, Monday - Friday between 8 a.m. and 6 p.m.

All fields are required unless otherwise noted.

Appointment

You must provide a date 24 hrs in the future.
(mm/dd/yyyy) Appointment date must be at least 24 hours in the future.

Patient Information

Patient first name is required.
Patient middle initial is required.
Patient last name is required.
Patient previous name is required.
(E.g. maiden name)
Patient date of birth is required and must be a valid date.
(mm/dd/yyyy)
Patient SSN must be in 555-55-5555 format
(999-99-9999)
Patient marital status is required.
Patient gender is required.
Patient race is required.
Patient address is required.
Patient address is required.
Patient city is required.
Patient state/province is required.
Patient state/province is required.
Patient ZIP/postal code is required.
Patient email must be a valid email address.
If provided, we will email you a confirmation that your pre-registration was received.
Patient home phone number must be in 555-555-5555 format.
Patient cell phone number must be in 555-555-5555 format.
Patient preferred contact method is required.
Employer
Patient employer name is required.
Patient retirement date must be a valid date.
Patient Employer phone must be in 555-555-55555 format.
Patient Employer address is required.
Patient Employer address is required.
Patient employer city is required.
Patient employer state/province is required.
Patient employer state/province is required.
Patient employer ZIP/postal code is required.

Guarantor

(for patients under age 18)
Guarantor first name is required.
Guarantor middle initial is required.
Guarantor last name is required.
Guarnator previous name is required.
(i.e. maiden name)
Guarantor date of birth must be a valid date.
(mm/dd/yyyy)
Guarnator marital status is required.
Guarantor gender is required.
Guarantor address is required.
Guarantor address is required.
Guarantor city is required
Guarantor state/provice is required.
Guarantor state/provice is required.
Guarantor ZIP/postal code is required.
Guarantor home phone must be in 555-555-5555 format.
Employer
Guarantor employer name is required.
Guarantor employer phone must be in 555-555-5555 format.
Guarantor employer address is required.
Guarantor employer address is required.
Guarantor employer city is required.
Guarantor employer state/province is required.
Guarantor state/province is required.
Guarantor employer ZIP/postal code is required.

Next of Kin

(Emergency Contact)
Next of kin first name is required.
Next of kin middle initial is required.
Next of kin last name is required.
Next of kin relationship to patient is required.
Next of kin date of birth must be a valid date.
(mm/dd/yyyy)
Next of kin address is required.
Next of kin address is required.
Next of kin city is required.
Next of kin state/province is required.
Next of kin state/province is required.
Next of kin ZIP/postal code is required.
Next of kin home phone must be in 555-555-5555 format.
Employer
Next of kin employer name is required.
Next of kin retirement date must be in mm/dd/yyyy format.
Next of kin address is required.
Next of kin address is required.
Next of kin employer city is required.
Next of kin employer state/province is required.
Next of kin employer state/province is required.
Next of kin employer ZIP/postal code is required.
Next of kin employer phone must be in 555-555-5555 format.

Insurance or Medicaid Information

Insurance status is required.
Company 1
Insurance Company 1 type is required.
Insurance Company 1 name is required.
Insurance Company 1 subscriber name is required.
Insurance Company 1 relationship to patient is required.
Insurance Company 1 policy number is required.
Insurance Company 1 group number is required.
Employer
Insurance Company 1 Employer name is required.
Insurance Company 1 Employer address is required.
Insurance Company 1 Employer address is required.
Insurance Company 1 Employer city is required.
Insurance Company 1 Employer state/province is required.
Insurance Company 1 Employer state/province is required.
Insurance Company 1 Employer ZIP/postal code is required.
Company 2 (if applicable)
Insurance Company 2 type is required.
Insurance Company 2 name is required.
Insurance Company 2 subscriber name is required.
Insurance Company 2 relationship to patient is required.
Insurance Company 2 policy number is required.
Insurance Company 2 group number is required.
Employer
Insurance Company 2 Employer name is required.
Insurance Company 2 Employer address is required.
Insurance Company 2 Employer address is required.
Insurance Company 2 Employer city is required.
Insurance Company 2 Employer state/province is required.
Insurance Company 2 Employer state/province is required.
Insurance Company 2 Employer ZIP/postal code is required.
MSP Questionnaire
(to be completed by all patients on Medicare)
1. Is this visit covered under Black Lung benefits, Dept. of Veteran Affairs, or other grants?
MSP Question 1 is required.
2. Was your illness/injury due to an Automobile or other accident?
MSP Question 2 is required.
3. Was your illness/injury due to an accident or illness that occurred at work?
MSP Question 3 is required.
4. Do you or your spouse work for a company that provides you with health insurance?
MSP Question 4 is required.
5. Are you entitled to Medicare based on
MSP Question 5 is required.

Special Program

Special program name is required.
EDP (Early Detection Program)

Do you want to receive appointment reminders?

Text
Please indicate if you'd like to receive text reminders.
Voice Mail
Please indicate if you'd like to receive voicemail reminders.
Email
Please indicate if you'd like to receive email reminders.
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Reminder

Please bring all insurance cards and a photo ID at time of service. Co-pays, deductibles, or other patient responsibility will be collected at time of service. Financial Assistance or payment arrangements are available for those who qualify. For more information, call 860-358-4870 or visit middlesexhealth.org. Use keyword search "Financial Assistance" or "Billing".