Radiology and Imaging Pre-Register | UnityPoint Health - Dubuque

To register for your Radiology/Imaging Services procedure, please complete the following information and click submit.  Preregistration should be completed 24-48 hours before your appointment.

Please view our Privacy Policy to learn about the secure electronic handling of your personal information.

Please bring your Insurance Card and Picture ID with you on the day of admission.

Accident Related?
If yes, is this Workers comp?
Are you scheduled to have more than one type of exam?

Patient Information

Marital Status
Translation/Interpreter Services Needed?


Employment Status (if applicable)

Emergency Contact Information

Insurance Information

Primary Insurance Company *
Secondary Insurance? (If yes, please complete section)

Other Information

Spiritual needs are important to some patients, would you like us to notify your Pastor of your admission?