Houston Methodist. Leading Medicine.
Houston Methodist. Leading Medicine

Email Forms Manager

To register for your procedure, please contact 832.522.1170 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 
Daytime Phone Number * 
Evening Phone Number 
E-mail Address * 
Date Of Birth * 
Social Security Number (If none, enter, 888-88-8888) * 
Gender * 
Race (State Requirement) * 
Marital Status * 
City Code (International patients only) 
Country Code (International patients only) 
May We Contact You at the E-mail Address Above? * 
If Not, Please Provide Your Contact Information 
Your Information 
Your Name (if you are not the patient) 
Your Phone Number 
Your City Code (international only) 
Your Country Code (international only) 
Your Address * 
Your City, State, Zip Code 
Your Country 
Your E-mail Address 
Your Relationship to the Patient 
Nearest Relative's Information 
Relative's Name * 
Nearest Relative's Relationship to the Patient * 
Relative's Address * 
Relative's City, State, Zip Code * 
Relative's Country 
Relative's Phone Number * 
Relative's City Code (international only) 
Relative's Country Code (international only) 
List Procedures to be Performed * 
Diagnosis/Symptoms (reason for procedure) * 
Physician Ordering the Procedure * 
Physician's Phone Number * 
Have These Procedures Been Scheduled? * 
Would You Like Us to Schedule These for You? * 
Date Requested for Procedure (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 Allergic to Latex? * 
Are You Pregnant? * 
Are You Allergic to Iodine? 
Employment Status 
Employer 
Employer's Address 
Employer's City, State, Zip Code 
Employer's Country 
Employer's Phone Number 
Is Patient's Insurance Through Employer? 
Insurance #1 
Does Insurance #1 Know The Patient Is Having This Procedure? 
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 
If You Have Additional Insurance Coverage, Or Worker's Compensation, Please Continue Registration Form. If Not, Please Scroll Down To Bottom To Complete Form and Submit. 
Insurance #2 
Does Insurance #2 Know The Patient Is Having This Procedure? 
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 
City, State, Zip Code #2 
Insurance #3 
Does Insurance #3 Know The Patient Is Having This Procedure? 
Insurance #3 Name 
Insurance #3 Type 
Insured's Name #3 
Insured's Date of Birth #3 
ID/Policy Number #3 
Is Insurance #3 A Group Policy? 
Group Name #3 
Group Number #3 
Telephone Number We Should Call To Verify Benefits #3 
Precertification Phone Number #3 
Billing Address #3 
City, State, Zip Code #3 
Insurance #4 
Does Insurance #4 Know The Patient Is Having This Procedure? 
Insurance #4 Name 
Insurance #4 Type 
Insured's Name #4 
Insured's Date of Birth #4 
ID/Policy Number #4 
Is Insurance #4 A Group Policy? 
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