This process will take approximately 30-45 minutes to complete and must be completed in one sitting. To ensure that your data is secure, each section will time-out if idle for more than 20 minutes. To prevent a time-out, we suggest you have the following items at hand before beginning the forms:
- Valid Drivers License
- Social Security Number
- Insurance Card
- Medication History
You will need to fill out either the Adult or Pediatric Patient Personal History followed by the Pre-Registration form.
CLICK HERE TO FILL OUT ADULT HEALTH HISTORY FORM
CLICK HERE TO FILL OUT PEDIATRIC HEALTH HISTORY FORM
HAGA CLIC AQUÍ PARA LLENAR EL FORMULARIO DE ANTECEDENTES MEDICOS PARA ADULTO
HAGA CLIC AQUÍ PARA LLENAR EL FORMULARIO DE ANTECEDENTES MEDICOS PARA PEDIATRICO
If you have any questions about our online pre-registration service or need assistance, please contact our Guest Relations team:
Direct Line: 214.647.5320
Email: gro.1521767504sfit@1521767504ofni1521767504Business Hours: Monday – Friday, 5 a.m. – 5 p.m. Closed on Major Holidays
FOR YOUR SECURITY AND PRIVACY PROTECTION:
We protect the personal information we have collected from this website by using industry standard HIPPA-compliant security precautions. Any information collected during the online pre-registration process is protected for your privacy and confidentiality. For more information, please refer to our Notice of Patient Privacy. Interpretation services are provided by the hospital free of charge. Please make sure to include a note if you will need interpretation services, so the hospital may make arrangements.