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​​​​​​​​​Baylor Scott & White Medical Center – White Rock

Please fill out the form below, and we’ll confirm with you when received if you have included a valid email address. At that time, we’ll also let you know if we need any additional information. ​

If this is an emergency, please dial 911 or go to the nearest emergency room. This form is not for ER registration.

Fields marked with an asterisk(*) are required. 

Note: Selecting the arrows in the title areas will expand and hide the pre-registration questions for your convenience.


Patient First Name: *
Patient Last Name: *
Patient Middle Initial:
Patient Maiden Name:
Place of Birth: *
(State or Country, if not U.S.)
Patient Birthdate: *
(mm/dd/yyyy)
Social Security Number: *
Patient's Gender: *
Marital Status: *
Race: *
Ethnicity: *
Preferred Language:
Religious Preference:
Address: *
City: *
State/Province: *
Zip/Postal Code: *
Telephone Number: *
Cell Phone Number:
Email Address:
Employment Status: *
Are you a returning patient?
Admitting Physician Name: *
Treating Physician Name: *
Primary Care Physician / Family Doctor:
Expected Admission / Due Date: *
Expected Admission Time:
Type of Procedure/Treatment/Test: *
Spouse or Guarantor's First Name: *
Spouse or Guarantor's Last Name: *
Relationship: *
Spouse or Guarantor's Social Security Number: *
Spouse or Guarantor Address: *
City: *
State/Province: *
Zip/Postal Code: *
Telephone Number: *
Spouse or Guarantor Employment Status: *


Contact Name: *
Relationship: *
Address: *
City: *
State/Province: *
Zip/Postal Code: *
Telephone Number: *
Nearest Relative or Friend (not living with you)
Nearest Relative Name: *
Relationship: *
Address: *
City: *
State/Province: *
Zip/Postal Code: *
Telephone Number: *
Are you insured?

Do you have secondary insurance?

Best Way to Contact You:

Best Time to Contact You:


If there is a financial liability (i.e. Co-Payment, deductible, etc.), what is your preferred method of payment?



​​Contact Us

 

If you have questions about the pre-registration process, please contact us at 888.773.7342.

Return to the Main Baylor Scott & White – White Rock Website​