CHRISTUS Health Patient Pre-Registration

Welcome to CHRISTUS Health online patient pre-registration.

Please complete this convenient online patient pre-registration to save time on the day of your procedure. The pre-registration information must be completed at least three business days before your procedure. Note: Completing the online pre-registration form now will limit registration at the time of service to include signing of patient consents only. Please bring a photo ID, insurance card, and physician's orders on the day of the procedure.

CHRISTUS Health protects your confidential information and for this reason you are now in a secure window. Your information will be kept in strict confidence. For the health and safety of all, CHRISTUS Health campuses are tobacco-free.

Thank you for choosing CHRISTUS Health.

Have you been to a CHRISTUS facility?

Yes
No
Not Sure

First Name

Middle Name

Last Name

SSN

DOB

MonthDayYear

Sex

Marital Status

Language Preference

Ethnicity

Race

Street Address

APT/Unit/Lot #

City

State

Zip

Email Address

Home Phone

Cell Phone

Best time to contact

Morning
Day
Evening

What test/procedure scheduled for? If birthing delivery please indicate if the delivery will be a vaginal or c-section birth

Emergency Contact Name

Emergency Contact Phone

Emergency Contact's Relationship to Patient

Guarantor/Responsible Party (if different from above)

Responsible Party's Last Name

Responsible Party's First Name

Responsible Party's Middle Name

Relationship to Patient

Responsible Party's DOB

MonthDayYear

Responsible Party's Address

Responsible Party's City

Responsible Party's State

Responsible Party's Zip

Responsible Party's Email Address

Responsible Party's Home Phone

Responsible Party's Cell Phone

Responsible Party's Employer Name (If not employed, enter NONE)

Responsible Party's Employer Address

Responsible Party's Employer City

Responsible Party's Employer State

Responsible Party's Employer Zip

Patient Insurance Information (Please bring insurance card and photo ID)

Primary Insurance Company Name ( enter none if self-pay)

Insurance Address

Insurance City

Insurance State

Insurance Zip

Name of Policy Holder

Date of Birth

MonthDayYear

Policy Holder Employer

Employment Status

Insurance ID Number

Group Number

Primary Insurance Phone Number

Secondary Insurance Company's Name

Secondary Insurance Address

Secondary Insurance City

Secondary Insurance State

Secondary Insurance Zip

Secondary Insurance Phone Number

Name of Policy Holder

Relationship to Patient

Date of Birth

YearMonthDay

Policy Holder Employer

Employment Status

Insurance ID Number

Group Number

Primary Care Physician (PCP)

PCP Physician First Name

PCP Physician Last Name

PCP Phone

Ordering Physician (OP)

OP First Name

OP Last Name

Maternity Patients

If maternity services for delivery, what is your due date?

MonthDayYear

What was the date of your last menstrual period?

MonthDayYear

CHRISTUS Facility

CHRISTUS Facility that the procedure will take place

Newborn Physician Information

Pediatrician Name

Pediatrician Phone Number

Terms and Conditions

I agree to Terms and Conditions below

Thank you for choosing CHRISTUS Health. We realize you have a choice in your healthcare providers. We are honored you have chosen us for your upcoming service.

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.