Contact Us     Maps & Directions     About Us
Find a Provider
Your Medical Home
Find a Facility
Plan Your Visit
Find a Provider
Giving
Mother Frances Hospital
Heart Hospital
Neuroscience Institute
Orthopedics and Sports Medicine
Patient Pre-Registration

At Trinity Mother Frances Hospitals and Clinics, our goal is to provide high quality and efficient care. For your convenience, we offer tools online that help streamline the registration process for both hospital and Trinity Clinic services. Your information is protected by law and will be used solely to register you for services.

Pre-Registration for Trinity Clinic Patients
Trinity Clinic patients can save time at check-in. Please print out and complete the following forms and bring them with you to your appointment. If you have any questions about your scheduled appointment, please call your provider's office.

Click here to view your registration packet. Please print out and complete the forms and bring them with you to your scheduled appointment.

Please note:
- Patients who complete this form in advance will still need to be checked in at the clinic to finalize registration.
- Please bring your insurance cards, photo I.D. and a list of medications you are currently taking.
- You may be contacted by the facility in advance of your scheduled appointment to obtain or provide additional information.

Pre-Registration for Hospital Services
Patients scheduled for testing, surgery, child birth or rehabilitation, please fill out the confidential form below. If you have any questions about your scheduled procedure, please call our pre-registration line at (903) 531-5335 or (800) 269-6807. We are available to take your call on weekdays from 8 a.m. to 8 p.m.

Use this form ONLY IF your procedure:
- Has already been scheduled AND/OR
- It is maternity related

Please note:
- You should complete the pre-registration form 72 hours prior to your visit.
- Patients who complete this form still need to go to the Registration/Admissions office to finalize registration.
- Please bring your insurance cards and photo I.D.
- You may be contacted by the facility in advance of your scheduled procedure to obtain or provide additional information.


* Indicates required information
Patient Information 
Type of Registration: * 
* If selecting SURGERY, please view the PASS page before your scheduled procedure. 
Date of Service: * 
Physician who scheduled your appointment: * 
Onset Date: (How long have you been having problems) * 
Patient Name: (As it appears on your driver's license) * 
Social Security Number: * 
Date of Birth: * 
Address: * 
City: * 
State * 
Zip Code: * 
Home Phone: * 
Work Phone: * 
Employer: * 
Employer Address: 
Marital Status: * 
Religious Preference: 
Guarantor/Insured Information 
Guarantor or Insured is the person whose insurance will cover you. If private pay, provide responsible party's information. 
If Private Pay, check this box: 
Guarantor Name: * 
Social Security Number: * 
Date of Birth: * 
Address: * 
City: * 
State: * 
Zip Code: * 
Home Phone: * 
Work Phone: * 
Employer: * 
Employer Address: 
Emergency Contact Information 
Contact Name: * 
Relationship: * 
Phone Number: * 
Insurance Information 
Insurance Company: * 
Address: 
City: 
State: 
Zip Code: 
Phone Number: * 
Policy Holder/Name of Insured: * 
Policy/Claim No: * 
Group No: * 
Other Insurance Information 
Do you have any other insurance coverage? 

If so, please complete the information below: 
Insurance Company: 
Address: 
City: 
State: 
Zip Code: 
Phone Number: 
Policy Holder/Name of Insured: 
Policy/Claim No: 
Group No: 
Clinical Information: 
This visit is related to: * 




If Other, please specify:

If Accident: Date and Time 
If Accident, Please select type: * 

If Other, please specify:

Comments: 
Email Address: *