Hospital Registration

To register for your procedure, please complete the form below.

  • Attention Childbirth - Registering for a childbirth? Use this Childbirth Registration form. Do not use the form below.
  • Confirmation - A representative will contact you by the next business day to confirm or discuss your request.
  • Procedure in 24 hours - If your procedure is scheduled to occur within the next 24 hours, please contact us at the scheduling office for your location.
  • Preferred way we contact you - Communication via email may not be secure. Keep this in mind when deciding how you prefer us to contact you.
  • Data privacy - To protect your privacy, our online form data is encrypted and stored in a secure location.
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 *
Identification: To speed up your registration, please upload your valid Identification (driver's license, state or military issued identification or valid passport.) Upload a photo (jpg/jpeg, png) or pdf file smaller than 4 MB.
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
Insurance Card: To speed up your registration, if available, please upload a photo (jpg/jpeg, png) or pdf document of BOTH sides of your insurance card. Uploaded files must be smaller than 4 MB.
Is the patient the subscriber? (The subscriber is the policy holder; the person whose employer provides the insurance you are using.) *
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
Insurance Card: To speed up your registration, if available, please upload a photo (jpg/jpeg, png) or pdf document of BOTH sides of your insurance card. Uploaded files must be smaller than 4 MB.
Is the patient the subscriber? (The subscriber is the policy holder; the person whose employer provides the insurance you are using.) *
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 *
What is your preferred local pharmacy? (include address and/or cross streets)
Do you currently have a Texas Advanced Directive you would like to put on file with Houston Methodist? Example forms include: Medical power of attorney, DNR (Do not resuscitate), and Directive to Physicians and Family.
If you are able, please upload your Advanced Directive document(s) as a photo (jpg/jpeg, png) or pdf file type. The uploaded file must be smaller than 4 MB.
Are you pregnant? *
Would you like to participate in a program with Houston Methodist and the Texas Department of State Health Services (DSHS) (called ImmTrac2) in which both organizations bi-directionally share immunization information? *
Click to learn the Benefits of Participating in the Texas Immunization Registry.
I would like to stay connected with Houston Methodist on upcoming events, health tips and newsletters.
Authentication *