General Registration (Not Maternity)

All patients (except maternity) with a scheduled procedure date should complete the General Pre-Registration form below, at least three days prior to admission. Maternity patients should complete the online Maternity Pre-Registration form by the seventh month of your pregnancy. If your admission is not yet scheduled, please contact your physician to arrange a procedure date and time and then return to this website to complete your online pre-registration.

I understand that any information submitted to Methodist Health System on this website is encrypted and will be used by Methodist Health System only for the purpose of registration and/or medical records. Uses of the information will follow all federal and state laws and regulations related to medical record privacy. I understand that I voluntarily submit information here, and that I also have the option of completing registration in person at any Methodist Health System hospital.

By filling out this form and clicking on the "submit" button below, you agree and accept the above statements.

Asterisk indicates a required field.

Choose Hospital*

Hospital Location is required.
Last Name*

Last Name is required.
First Name*

First Name is required.
Middle Name
Maiden Name
Street Address 1*

Address is required.
Street Address 2
City*

City is required.
State*

State is required.
ZIP Code*

ZIP Code is required.
Preferred Phone Number*

This isn't a valid phone number.

Preferred Phone Number is required.

You entered an invalid number.
Patient's l Security Number (###-##-###)*

Patient's Social Security Number (###-##-###) is required.
Patient's Gender*

Patient's Gender is required.
Marital Status*

Marital Status is required.
Race*

Race is required.
Ethnicity*

Ethnicity is required.
Clergy Visit*

Clergy Visit is required.
Patient Date of Birth*

Patient Date of Birth is required.
Email Address*

This isn't a valid email address.

Please enter your email address.
Have you been admitted to Methodist Health System before?

Please make a selection.
Admitted Date*

Please enter your admission date.
Discharge Date*

Please enter your discharge date.
Hospital Name
Patient Name At Admission
Employment Status
Occupation
Patient Employer
Employer Street Address 1
Employer Street Address 2
Employer City
Employer State
Employer ZIP Code
Employer Phone
How Long?
Spouse/Parent/Legal Guardian (SPG) Relationship to Patient
SPG Name
SPG Employer
SPG Employer Street Address 1
SPG Employer Street Address 2
SPG Employer City
SPG Employer State
SPG Employer ZIP Code
SPG Occupation
SPG Employer Phone

This isn't a valid phone number.
Guarantor's Relationship to Patient*

Guarantor's Relationship to Patient is required.
Guarantor's Name
Guarantor's Street Address 1*

Guarantor's Street Address 1 is required.
Guarantor's Street Address 2
Guarantor's City*

Guarantor's City is required.
Guarantor's State*

Guarantor's State is required.
Guarantor's ZIP Code*

Guarantor's ZIP Code is required.
Guarantor's Home Phone*

This isn't a valid phone number.

Please enter your phone number.

You entered an invalid number.
Guarantor's Gender*

Guarantor's Gender is required.
Guarantor's Date of Birth*

Guarantor's Date of Birth is required.
Guarantor's Social Security Number (###-##-###)*

Guarantor's Social Security Number (###-##-###) is required.
Guarantor's Occupation*

Guarantor's Occupation is required.
Guarantor's Employer
Guarantor's Employer Street Address 1
Guarantor's Employer Street Address 2
Guarantor's Employer City
Guarantor's Employer State
Guarantor's Employer ZIP Code
Guarantor's Employer Phone

This isn't a valid phone number.
How Long?
In Case of Emergency, Notify*

Emergency Contact is required.
Emergency Contact Street Address 1*

Emergency Contact Street Address 1 is required.
Emergency Contact Street Address 2
Emergency Contact City*

Emergency Contact City is required.
Emergency Contact State*

Emergency Contact State is required.
Emergency Contact ZIP Code*

Emergency Contact ZIP Code is required.
Emergency Contact Home Phone*

This isn't a valid phone number.

Emergency Contact Home Phone is required.

You entered an invalid number.
Emergency Contact Work Phone*

This isn't a valid phone number.

Emergency Contact Work Phone is required.

You entered an invalid number.
Emergency Contact's Relationship to Patient*

Emergency Contact's Relationship to Patient is required.
Other Near Relative Name
Other Near Relative Contact Address 1
Other Near Relative Contact Address 2
Other Near Relative Contact City
Other Near Relative Contact State
Other Near Relative Contact ZIP Code
Other Near Relative Contact Phone

This isn't a valid phone number.

You entered an invalid number.
Other Near Relative Relationship to Patient
Primary Care Provider Name*

Primary Care Provider Name is required.
Primary Care Provider Phone

This isn't a valid phone number.

You entered an invalid number.
Admitting Provider Name
Diagnosis
Religious Preference
Place of Worship
Reason for Visit*

Reason for Visit is required.
Scheduled Date of Visit*

Scheduled Date of Visit is required.
Is This Visit Related To An Accident?
If "Yes", Please Provide Accident Date And Time
If "Yes", Please Provide Accident Type
Primary Insurance Plan Type*

Primary Insurance Plan Type is required.
Is the patient the primary insurance holder?*

This field is required.
Primary Insurance Relationship to Patient*

Primary Insurance Relationship to Patient is required.
Primary Insurance Company Name
Primary Insurance Company Street Address 1
Primary Insurance Company Street Address 2
Primary Insurance Company City
Primary Insurance Company State
Primary Insurance Company ZIP Code
Primary Insurance Company Customer Service Phone Number
Primary Insurance Policy Number
Primary Insurance Group Number
Primary Insurance Policy Effective Date*

Primary Insurance Policy Effective Date is required
Primary Insurance Insured's Name*

Primary Insurance Insured's Name is required.
Primary Insurance Policy Insured's Social Security Number (###-##-####)*

Primary Insurance Policy Insured's Social Security Number (###-##-####) is required.
Primary Insurance Policy Insured's Date of Birth*

Primary Insurance Policy Insured's Date of Birth is required.
Primary Insurance Insured's Employer Name
Primary Insurance Insured's Employer Street Address 1
Primary Insurance Insured's Employer Street Address 2
Primary Insurance Insured's Employer City
Primary Insurance Insured's Employer State
Primary Insurance Insured's Employer Zip
Primary Insurance Insured's Employer Phone

This isn't a valid phone number.

You entered an invalid number.
Primary Insurance - Is Precertification Required?*
- Yes
- No
- Do not know
Primary Insurance - Is Precertification Required? is required.
Primary Insurance - Have You Called To Precertify The Admission?*
- Yes
- No
- Do not know
Primary Insurance - Have You Called To Precertify The Admission? is required.
Primary Insurance Preauthorization Number
Primary Insurance Preauthorization Phone Number

This isn't a valid phone number.

You entered an invalid number.
Do you have secondary insurance?
Secondary Insurance Plan Type
Secondary Insurance Relationship To Patient
Secondary Insurance Company Name
Secondary Insurance Company Street Address 1
Secondary Insurance Company Street Address 2
Secondary Insurance Company City
Secondary Insurance Company State
Secondary Insurance Company ZIP Code
Secondary Insurance Customer Service Phone Number

This isn't a valid phone number.

You entered an invalid number.
Secondary Insurance Policy Number
Secondary Insurance Group Number
Secondary Insurance Policy Effective Date*

Secondary Insurance Policy Effective Date is required
Secondary Insurance Insured's Name
Secondary Insurance Insured's Social Security Number (###-##-####)
Secondary Insurance Insured's Date of Birth*

Secondary Insurance Insured's Date of Birth required.
Secondary Insurance Insured's Employer Name
Secondary Insurance Insured's Employer Street Address 1
Secondary Insurance Insured's Employer Street Address 2
Secondary Insurance Insured's Employer City
Secondary Insurance Insured's Employer State
Secondary Insurance Insured's Employer ZIP Code
Secondary Insurance Insured's Employer Phone
Secondary Insurance - Is Precertification Required?
- Yes
- No
- Do not know
- None
Secondary Insurance - Have You Called To Precertify The Admission?
- Yes
- No
- Do not know
- None
Secondary Insurance Preauthorization Number
Secondary Insurance Preauthorization Phone Number

This isn't a valid phone number.

You entered an invalid number.
Name of Medical Power of Attorney (if applicable)
Phone of Medical Power of Attorney (if applicable)

This isn't a valid phone number.

You entered an invalid number.