For your convenience Belleville Surgical Center is now offering online pre-registration for your surgery.  There are three forms you need to complete, the pre-registration form, medical sheet and health history form.  Registration is designed to be quick and easy and completing the form should take you 10-15 minutes.  Please have your insurance information handy. A nurse from the Surgical Center will review your health history.  If necessary she will review it with the Anesthesiologist.  She will call you with your pre-operative instructions and give you  the time you will need to arrive at the facility.

You may also download the registration forms in .pdf format if you prefer.

Please submit your online pre-registration at least 1 week in advance of check-in to ensure timely processing.

If you choose to utilize our Pre-registration Form, understand that you do so at your own choice and risk. Any information you submit via the Pre-registration Form is confidential and is only shared with third parties as outlined in our Privacy Pledge. For more information, please read our Patient Privacy Notice.

Pre-registration Disclaimer

If you elect to electronically submit a completed Pre-registration Form or any other information to Belleville Surgical Center through this web site, you agree that you do so at your own choice and risk, and that you assume all responsibility for any liability arising from such electronic submission and from any errors or omissions in the data you provide. You agree to release and hold Belleville Surgical Center  and its affiliates (including its directors, officers, employees, shareholders, agents and representatives) harmless from any and all liability or cause of action arising from the interception, access or use by a third party of any information submitted electronically by you through this web site and from any errors or omissions in the data you provide. Additionally, the provision of any information to Belleville Surgical Center by you through this web site, including a completed Pre-registration Form, does not create or constitute any relationship between you and Belleville Surgical Center, its affiliates, or any of the physicians on its staff, to which any privilege may attach.