Beaver Dam Community Hospitals, Inc.

Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speeding up your office visit and allowing us to better serve your healthcare needs. If you are completing this on a mobile device, please be sure to enter the phone number with the format (123) 456-7890 or it will not allow you to complete the form. Please call us with any issues or concerns (920) 821-0071

Who are you?