Pre-Register for Your Hospital Stay

CHRISTUS Facility

Select the facility that you will have your procedure at: CHRISTUS Childrens CHRISTUS Santa Rosa Hospital - Alamo Heights CHRISTUS Santa Rosa Hospital - Medical Center CHRISTUS Santa Rosa Hospital - New Braunfels CHRISTUS Santa Rosa Hospital - San Marcos CHRISTUS Santa Rosa Hospital - Westover Hills CHRISTUS Shreveport-Bossier Health System CHRISTUS Southeast Texas Hospital - St. Elizabeth CHRISTUS St. Frances Cabrini Hospital Have you been to a CHRISTUS facility? Yes No Not Sure

General Patient Information

* First Name Middle Name * Last Name Social Security Number * Date of Birth Sex Female Male Marital Status Married Divorced Widowed Single Widow/Widower Legally Separated Unknown Language Preference English Espanol Ethnicity Hispanic/Latin Not of Hispanic/Latino Race African-American/Black American Indian/Native Alaskan Asian/Oriental/Eastern Indian Native Hawaiian White/Hispanic Decline Unknown * Street Address Street Address 2 * City * State * Zip Code * Email Address * Home Phone Cell Phone Best time to contact you? Morning Day Evening

Test/Procedure

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

Emergency Contact Information

* Name * Phone Number * Relationship to the Patient

Guarantor/Responsible Party Information

(If different from above)

First Name Middle Name Last Name Relationship to Patient Social Security Number Date of Birth Street Address Street Address 2 CIty State Zip Code Email Address Cell Phone Employer Name (If not employed, enter None) Employer Address Employer City Employer State Employer Zip

Patient Insurance Information

Enter Not Applicable (N/A) if self pay

Please bring insurance card and photo ID

* Primary Insurance Company Name * Insurance Address * Insurance City * Insurance State * Insurance Zip * Name of Policy Holder * Relationship to Patient * Date of Birth * Policy Holder Employer * Employment Status Full Time Part Time * Insurance ID Number * Group Number * Primary Insurance Phone Number

Patient Secondary Insurance Information

Secondary Insurance Company's Name Secondary Insurance Address Secondary Insurance City Secondary Insurance State Secondary Insurance Zip Name of Policy Holder Relationship to Patient Date of Birth Policy Holder Employer Employment Status Full Time Part Time Insurance ID Number Group Number

Tell Us About Your Primary Care Physician

Do you have a primary care physician? Yes No

If yes, please tell us about them:

* Primary Care Physician First Name * Primary Care Physician Last Name * Primary Care Physician Phone Number

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

* Ordering Physician First Name * Ordering Physician Last Name

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.

Expected due date Date of your last menstrual cycle

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

Pediatrician Yes No Pediatrician First Name & Last Name Pediatrician Phone Number

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.

* Terms and Conditions Yes No