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 *
Apartment/Unit
City *
State *
State
Postal code *
City code *
Country code *
Primary phone number *
Email *
Confirm email *
Preferred way we contact you *
Date of birth *
Patient's gender *
Social security number *
Race
Ethnicity
Marital status *
Your Information
Are you the patient?
Your name *
Country
Your phone number *
Is your address the same as the patient?
Your address *
City *
State *
State
Postal Code *
City Code *
Country Code *
Your email address
Confirm email address
Your relationship to the patient *
Emergency Contact Information
Emergency contact name *
Emergency contact phone number *
Relationship to patient *
Alternate contact name
Alternate contact phone number
Alternate contact relationship to patient
Employment Information
Employment status
Employer name
Insurance Information
Do you have insurance? *
Health insurance plan name *
Health insurance type *
Member ID number *
Group number
Insurance's customer service phone number
Is patient the subscriber *
Name of the subscriber *
Relationship to patient *
Subscriber Date of birth *
Subscriber's employer name *
Medical recipient number *
Name on Medicare card *
Medicare number *
Part A effective date *
Part B effective date
Do you have secondary insurance coverage? (Insurance 2) *
Secondary insurance plan name *
Health insurance type *
Member ID number *
Group number
Insurance's customer service phone number
Is the patient the subscriber? *
Name of the subscriber *
Relationship to the patient *
Subscriber date of birth *
Subscriber's employer name *
Medical recipient number *
Name on Medicare card *
Medicare number *
Part A effective date *
Part B effective date
Insurance Information
Are you a self-paying patient? *
Do you have health insurance? *
If yes, what is the name of your insurance? *
Have you notified your insurance of this procedure? *
Procedure Details
List procedure(s) to be performed *
Diagnosis/Symptoms (reason for procedure) *
Physician ordering the procedure *
Physician ordering the procedure's phone number *
Have these procedures been scheduled? *
If no, please indicate 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? *
I would like to stay connected with Houston Methodist on upcoming events, health tips and newsletters.
Authentication *