Refer a Patient to the Houston Methodist Lung Center

This form is for physicians referring patients only. If you are a patient, please complete this Houston Methodist Lung Center - Patient Request an Appointment form instead.

The Houston Methodist Lung Center evaluates patients with a wide variety of breathing disorders, from the common to the complex.

Every effort will be made to contact your patient within 2 business days to schedule an appointment.
If you would like to schedule an appointment over the phone you can call us directly at 713.441.7779.
Completing and submitting this form to the Houston Methodist Lung Center does not guarantee an appointment was made.
Please fax relevant patient medical records to 713.796.1701.

Patient Information

First Name * Last Name * Caregiver's Name Gender * Male Female Prefer not to answer Date of birth * Address 1 * Address 2 City * State * ZIP code * Phone Number * Email Address * Medications Patient's Medical Concerns (please include ICD-9 codes if known) *

Physician Information

Physician Name (if applicable) Address Phone Number Fax Number Email Address (referring physicians must provide an email address) * How did you hear about the Houston Methodist Lung Center?

Authentication *

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Refer a Patient to the Houston Methodist Lung Center

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