Contact Us

At Beloit Health System we appreciate hearing from our patients and community members. Please submit the following information so we can respond to your questions or comments.

If you are experiencing a medical concern, please call 911 or go immediately to an Emergency Center. The "Contact Us"; form is not intended to give specific medical advice or be used in an emergency. Do not request refills on the below form.

Please note this is not your healthcare portal, this form should not be used for medication requests, appointment changes, contacting your physician etc. Please contact your physician's office to make an appointment or renew medication. (You may want to sign up for our MyHealth Patient Portal that will allow you to communicate via the internet with your physician through our secure site. Managing your health and wellness has never been easier!)

Personal Information

* Indicates Required Field
First Name*

Please enter your first name.
Last Name*

Please enter your last name.
Email Address*

This isn't a valid email address.

Please enter your email address.
Phone Number*

This isn't a valid phone number.

Please enter your phone number.

You entered an invalid number.
Best time to reach you*

Please make a selection.
Best Method Of Contact*

Please make a selection.
How may we help you?*

Please make a selection.
Message Input

Please enter your message.