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 name
Patient's last name *
Country *
Patient's address *
City *
State *
Postal code *
City code *
Country code *
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 law) *

Your Information
Are you the patient?
Your name *
Your phone number *
Is your address the same as the patient?
Your address *
State *
Postal code *
City code *
Country code *
Your email address
Confirm email address
Your relationship to the patient *
Emergency Contact Information
Marital status *
Is spouse the emergency contact? *
Spouse's Name *
Spouse's phone number *
Spouse's email address *
Emergency contact's name *
Emergency contact's phone 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 *
Postal 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 *
Requested/Service Date/Time
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
Postal code
Employer's country
Employer's phone number
Is patient's insurance through employer?
Insurance Information
Do you have insurance? *
Do you have Medicare? *
Name on Medicare card *
Medicare number *
Part A effective date *
Part B effective date
Recipient number *
Case number*
Workers Compensation
Is this procedure due to an accident (workers compensation)? *
Date of accident *
Employer at time of accident *
Country accident occurred *
State accident occurred *
Adjuster's name *
Adjuster's phone number *
Adjuster's billing address *
Adjuster's city, state, postal 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? *
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? *
I would like to stay connected with Houston Methodist on upcoming events, health tips and newsletters.
How did you hear about us? *
If other, please specify *
Authentication *
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