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Mammography Pre-Registration

Welcome to Middlesex Hospital's On-line Pre-Registration for Screening Mammogram Appointments

As a convenience for our patients, Middlesex Hospital offers pre-registration for patients with a mammogram appointment.

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.

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, 8 a.m. - 6:00 p.m.


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

Patient Information

(i.e. maiden name)


You must provide at least one phone number.

If provided, we will email you a confirmation that your pre-registration was received.


Guarantor Information (for patients under age 18)

(i.e. maiden name)


Next of Kin (Person you would like called in case of emergency)



Insurance or Medicaid Information
Special Program

EDP (Early Detection Program)

Insurance Company 1
Insurance Company 2 (if applicable)
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?

2. Was your illness/injury due to an Automobile or other accident?

3. Was your illness/injury due to an accident or illness that occurred at work?

4. Do you or your spouse work for a company that provides you with health insurance?

5. Are you entitled to Medicare based on

Do you want to receive appointment reminders?

Text *

Voice Mail *

Email *


We want to make sure you are human :)

Leave this field empty


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 refer to Use keyword search "Financial Assistance" or "Billing".

28 Crescent Street
Middletown, CT 06457

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