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Non-Maternity Pre-Registration

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.

Pre-Register for Your Appointment

Asterisk indicates a required field.
  • Hospital Location is required.
  • Last Name is required.
  • First Name is required.
  • Address is required.
  • City is required.
  • State is required.
  • ZIP Code is required.
  • Preferred Phone Number is required.
  • Patient's Social Security Number (###-##-###) is required.
  • Patient's Gender is required.
  • Marital Status is required.
  • Race is required.
  • Ethnicity is required.
  • Clergy Visit is required.
  • Patient Date of Birth is required.
  • This isn't a valid email address.
    Please enter your email address.
  • This is required.
  • Admitted Date is required
  • Discharge Date is required
  • This isn't a valid phone number.
  • This isn't a valid phone number.
  • Guarantor's Relationship to Patient is required.
  • Guarantor's Street Address 1 is required.
  • Guarantor's City is required.
  • Guarantor's State is required.
  • Guarantor's ZIP Code is required.
  • This isn't a valid phone number.
  • Guarantor's Gender is required.
  • Guarantor's Date of Birth is required.
  • Guarantor's Social Security Number (###-##-###) is required.
  • Guarantor's Occupation is required.
  • This isn't a valid phone number.
  • Emergency Contact is required.
  • Emergency Contact Street Address 1 is required.
  • Emergency Contact City is required.
  • Emergency Contact State is required.
  • Emergency Contact ZIP Code is required.
  • This isn't a valid phone number.
    Emergency Contact Home Phone is required.
  • This isn't a valid phone number.
    Emergency Contact Work Phone is required.
  • Emergency Contact's Relationship to Patient is required.
  • This isn't a valid phone number.
  • Primary Care Provider Name is required.
  • This isn't a valid phone number.
  • Reason for Visit is required.
  • Scheduled Date of Visit is required.
  • Primary Insurance Plan Type is required.
  • Primary Insurance Relationship to Patient is required.
  • This isn't a valid phone number.
  • Primary Insurance Policy Effective Date is required
  • Primary Insurance Insured's Name is required.
  • Primary Insurance Policy Insured's Social Security Number (###-##-####) is required.
  • Primary Insurance Policy Insured's Date of Birth is required.
  • This isn't a valid phone number.
    Primary Insurance - Is Precertification Required? is required.
    Primary Insurance - Have You Called To Precertify The Admission? is required.
  • This isn't a valid phone number.
  • This isn't a valid phone number.
  • Secondary Insurance Policy Effective Date is required
  • Secondary Insurance Insured's Date of Birth required.
  • This isn't a valid phone number.