Houston Methodist. Leading Medicine.
Houston Methodist. Leading Medicine

Email Forms Manager

To register for your procedure, please contact 713.394.6805 or complete the form below. If 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 phone number above to ensure a timely registration.

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 e-mail may not be secure, so please consider that when selecting a way for us to contact you. If you select phone or e-mail as your preferred method of contact, every effort will be made to return your request by the next business day.

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Patient's First Name * 
Patient's Middle Initial 
Patient's Last Name * 
Patient's Address1 * 
Patient's Address2 
City * 
State * 
Zip Code * 
Country 
Work Phone Number * 
Home Phone Number 
E-mail Address * 
Date Of Birth * 
Social Security Number (If none, enter, 888-88-8888) * 
Gender * 
Race (State Requirement) * 
Marital Status 
How do you prefer that we contact you? * 
Emergency Contact 
Emergency Contact's Name 
Emergency Contact's Telephone Number 
List Procedures to be Performed * 
Diagnosis/Symptoms (reason for procedure) * 
Physician Ordering the Procedure * 
Physician's Phone Number * 
Have These Procedures Been Scheduled? * 
If no, then please select your appointment preference. 
Employment Status 
Employment Information 
Employer 
Employer's Address 
Employer's City, State, Zip Code 
Employer's Phone Number 
Is Patient's Insurance Through Employer? 
Insurance #1 
Insurance #1's Name 
Insurance #1 Type 
Insured's Name #1 
Insured's Date of Birth #1 
ID/Policy Number #1 
Is Insurance #1 A Group Policy? 
Group Name #1 
Group Number #1 
Telephone Number We Should Call To Verify Benefits #1 
Precertification Phone Number #1 
Billing Address #1 
City, State, Zip Code #1 
Additional Information #1 
Insurance #2 
Insurance #2 Name 
Insurance #2 Type 
Insured's Name #2 
Insured's Date of Birth #2 
ID/Policy Number #2 
Is Insurance #2 A Group Policy? 
Group Name #2 
Group Number #2 
Telephone Number We Should Call To Verify Benefits #2 
Precertification Phone Number #2 
Billing Address #2 
Additional Information #2 
City, State, Zip Code #2 
Worker's Compensation (if applicable) 
Date of Accident 
Employer at Time of Accident 
State Accident Occurred 
Country Accident Occurred 
Adjuster's Name 
Adjuster's Phone Number 
Adjuster's Billing Address 
Adjuster's City, State, Zip Code 
Additional Information #3 
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