Patient Registration

We thank you for choosing Texas Health Presbyterian Hospital Rockwall for your surgery and/or procedure.  We offer secure online pre-registration via the form below which you may complete 48 hours in advance of your scheduled appointment.  Please provide an email address in the form in order to receive an email confirmation.

On the day of your scheduled visit, check-in with our registration staff to sign the required consent forms, review the information submitted and complete the registration process.  Please bring photo identification and insurance cards at this time. 

You should allow 48 hours for the pre-registration information to be active in our system and available upon your arrival.


 

Registration Form

 

Patient Demographic Information

 
* Patients Full Name :
 
Department :
Confidential :
 
* First Name :
* Last Name :
 
Middle Name :
 
* Address 1 :
Address 2 :
 
* Country :
* City :
 
* State :
* Zip :
 
* County :
* Email :
 
* Phone :
* Cell Phone :
 
* Birth Date :
 
* SSN :
 
* Sex :
* Marital Status :
 
Advance Directives/Living Will:
Military :
 
* Smoker :
Race :
 
Religion :
Ethnicity :
 

Spouse/Other Contact Information

 
* First Name :
* Last Name :
 
* Home Phone :
* Cell Phone :
 
* Address :
 
* City :
* State :
 
Employer :
Employer City :
 
Employer State :
 

Notify in Case of Emergency

 
* First Name :
* Last Name :
 
* Relationship to Patient :
Address :
 
* City :
* State :
 
* Home Phone:
* Cell Phone :
 

Guarantor / Insurance

Guarantor Demographics

 
* Name :
* Cell Phone :
 
* Address 1:
* Email :
 
Address 2:
SSN :
 
* City :
* Birth Date :
 
* State :
* Sex:
 
* Zip :
* Retired :
 

Guarantor Work Information

 
Employer :
Occupation :
 
Main Address :
Location Address :
 
City :
Location State :
 
Phone :
Zip Code :
 

Insurance Information

 
Do you have insurance :
 
Primary Insurance Company :
 
Address :
City :
State :
 
Zip :
Insurance Phone :
Group #/MCR # :
 
Subscriber Name :
Insured DOB :
Sex :
 
Address :
City :
State :
 
Zip :
 
 
Employer :
Relationship to Patient :
 
Employer's Address :

 
Secondary Insurance Company :
 
Address :
City :
State :
 
Zip :
Insurance Phone :
Group #/MCR # :
 
Subscriber Name :
Insured DOB :
Sex :
 
Address :
City :
State :
 
Zip :
 
 
Employer :
Relationship to Patient :
 
Employer's Address :

 
Third Insurance Company :
 
Address :
City :
State :
 
Zip :
Insurance Phone :
Group #/MCR # :
 
Subscriber Name :
Insured DOB :
Sex :
 
Address :
City :
State :
 
Zip :
 
 
Employer :
Relationship to Patient :
 
Employer's Address :