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CHRISTUS Health Online Patient Preregistration

CHRISTUS Facility

General Patient Information

Test/Procedure

Emergency Contact Information

Guarantor/Responsible Party Information

(If different from above)

Patient Insurance Information

Enter Not Applicable (N/A) if self pay

Please bring insurance card and photo ID

Patient Secondary Insurance Information

Tell Us About Your Primary Care Physician

If yes, please tell us about them:

Let us know about the physician that order the procedure you are preregistering for:

If you are celebrating the birth of your baby with us, we are so happy that you've chosen CHRISTUS Health to share this monumental moment.

Do you already have a pediatrician selected for your precious newborn child? Tell us more about them:

Terms and Conditions

Users are advised that the information submitted through this form may be transmitted over unsecured email and releases CHRISTUS Health and its Associates, agents, and subcontractors from all responsibility or liability for any claims or damages arising from the content of the Email Form or the transmission thereof. By selecting the "I agree to Terms and Conditions" checkbox user acknowledges these terms and conditions and consents to transmission of the form.