Online Patient Pre-Registration Form

If you are having a test or procedure scheduled at UT Medical Center, please fill out the following form in its entirety. Please note there are three sections prior to submitting the form. Completing this form will help speed up your registration process on the date of service. You will still need to sign paperwork and let us make a copy of your insurance and photo ID on date of service.

Online pre-registrations are checked Monday - Friday, 8:00 a.m. - 4:00 p.m. Please allow at least one full business day before your appointment for your pre-registration form to be processed. If you have any questions, please contact the Patient Access Office at (865) 305-9501.

1. General Information




2. Patient Information



















3. Spouse or Parent/Guardian Information













4. Emergency Contact (someone not living with Patient)





5. Primary Insurance Information

Yes No









7. Secondary Insurance Information

NOTE: Please bring your insurance card with you on your scheduled date of service so we can make a copy for our records.