Registration

When you arrive at West Suburban Medical Center, please have your:

  • Driver's license, state identification card or any other form of picture ID
  • Insurance identification card
  • Your doctor’s order (if any)
  • A referral (if required by your insurance carrier)
  • A list of your current conditions, as well as prior procedures and surgeries

Admitting & Hospital Registration Hours

Admitting is open 24 hours a day, seven days a week.  Please call (708) 383-6200 for more information.

Pre-Registration

Please fill out the form below and we’ll confirm with you when received if you have included a valid email address. At that time we’ll also let you know if we need any additional information.

Fields marked with an asterisk(*) are required.

 

If not from USA, select "Outside U.S."
If not U.S.
mm/dd/yyyy
999-99-9999
999-999-9999
999-999-9999

Employment Information

999-999-9999

Admission Information

Are you a returning patient?*

Are you pregnant?

mm/dd/yyyy
mm/dd/yyyy

Spouse/Guarantor Information (Responsible Party)

If not from USA, select "Outside U.S."
999-999-9999

Emergency Notification

Emergency Contact

999-999-9999

Nearest Relative or Friend (not living with you)

999-999-9999

Primary Insurance Information

Are you insured?*

999-999-9999
999-999-9999
mm/dd/yyyy

Secondary Insurance Information

Do you have secondary insurance?*

999-999-9999
999-999-9999
mm/dd/yyyy
If there is a financial liability (i.e. Co-payment, deductible, etc.) what is your preferred method of payment?


Best way to contact you?

Best time to contact you?


Newsletter Registration