Hospital Registration Form

To register for your procedure, please complete the form below. If you are registering for childbirth, please use the Childbirth Registration form instead of this form. When you submit a form, a representative will contact you by the next business day to confirm or discuss your request. If your procedure is scheduled to occur within the next 24 hours, please contact us at the scheduling office for your location.

To protect your privacy, all of our online forms are encrypted and stored in a secure location. Please note that while our forms are secure, any communication via email may not be secure, so please consider that when selecting a way for us to contact you. If you select phone or email as your preferred method of contact, every effort will be made to return your request by the next business day.

Hospital Location
Hospital location for procedure *
Patient Information
Patient's first name *
Patient's middle initial
Patient's last name *
Country *
Patient's address 1 *
City *
State *
State *
Zip code *
City Code(International Patients Only) *
Country Code(International Patients Only) *
Daytime phone number *
Evening phone number *
Email *
Confirm email *
Preferred way we contact you*

Date of birth *
Patient’s gender
Social security number *
Social security number
Race(Required by the law) *

Your Information
Are you the patient? Y/N
Your name *
Your phone number*
Is your address the same as the patient?
Your address*
State *
State *
Zip code *
Your city code (international only)*
Country code(international only) *
Your email address
Confirm email address
Your relationship to the patient *
Emergency Contact Information
Marital status *
Is Spouse the Emergency Contact? Y/N *
Spouse's Name *
Spouse's phone number *
Spouse's email address *
Emergency contact's
name *
Emergency contact's telephone number *
Relationship to patient *
Nearest relative's name *
Nearest relative's relationship to the patient *
Relative's address *
Relative's city *
Relative's state *
Relative's state *
Zip code *
Relative's country *
Relative's phone number *
Relative's city code *
Relative's country code (International Only) *
Physician Information
Are you a physician registering the patient? *
Type of admission *
Physician's name *
Physician office email address *
Office contact name *
Office contact phone
number *
Office contact fax number *
Diagnosis/Chief Complaints *
ICD 9 Code *
Procedure or Possible Treatment *
CPT Code *
Employment Information
Employment status

If retired, provide retirement date
Employer's address
Employer's city
Employer's state
Employer's state
Zip code
Employer's country
Employer's phone number
Is patient's insurance through employer
Insurance Information
Do you have insurance?
Y/N *
Do you have Medicare? Y/N *
Name on Medicare card *
Medicare number *
Part A eff date *
Part B eff date
Recipient number *
Case number*
Workers Compensation
Is this procedure due to an accident (workers compensation)? *
Date of accident *
Employer at time of
accident *
State accident occurred *
State *
Country accident occurred *
Adjuster's name *
Adjuster's phone number *
Adjusters billing address *
Adjuster's city, state, zip code *
Additional information
Procedure Details
List procedure(s) to be performed *
Diagnosis/Symptoms (Reason for procedure) *
Physician ordering the Procedure *
Physician's phone number *
Have these procedures been scheduled? Y/N *
If no, please select your appointment preference (The date and time you select may not be available) *
Soonest date you'd like your procedure *
Latest date you'd like your procedure *
Time you would like your procedure *
Are you pregnant? *
Health Related Questions
Are you allergic to latex? *
Are you allergic to iodine? *
Would you like to stay connected with Houston Methodist?...By signing up, you will receive information on upcoming events, health tips and newsletters. Y/N *
How did you hear about
us? *
If other, please specify *
Authentication *