Immunization Pre-Registration

If intending to schedule an appointment with Custer Health, complete and submit the following information. 
Complete and submit the pre-registration for EACH person that will be schedule for an appointment.
Allow 24 hours for the system to update before calling your local office to schedule an appointment.

*WIC appointment - Please call your local WIC office to schedule an appointment.
**CPR and 1st Aid classes - Please click here to register.

Demographic Information
Insurance Information

If client has one of the following Insurance providers as their Primary Insurance, complete the Primary and Secondary Insurance Sections:  Sanford, BCBS, Medicaid, Mediare, Humana, Tricare, Champ VA, Railroad Medicare, or Medica (Zoster or Td/Tdap are not covered)

If client has an insurance provider not listed above, these are considered out of network and Custer Health cannot submit claims. Payment will be due at time of service. A receipt will be generated for your records.

Primary Insurance

Card Holder's Information

Secondary Insurance

Card Holder's Information

Person Financially Responsible for Client