Houston Methodist. Leading Medicine.
Houston Methodist. Leading Medicine

Email Forms Manager

To protect your privacy, all of our online forms are encrypted and stored in a secure location. Please note that while our forms are secure, any communication via e-mail may not be secure, so please consider that when selecting a way for us to contact you. If you select phone or e-mail as your preferred method of contact, every effort will be made to return your request by the next business day. A response to your request via postal mail may take up to 10 business days to receive.
* Indicates required information
Patient's First Name * 
Middle Initial 
Patient's Last Name * 
Patient's Address1 * 
City * 
State * 
Zip Code * 
Daytime Phone Number * 
Evening Phone Number 
E-mail Address * 
Date Of Birth (mm/dd/yyyy) * 
Clinic Appointment Date 
Clinic Appointment Time 
Clinic Appointment Location 
Place of Birth 
Social Security Number 
Fax Number 
Emergency Contact 
Business Information 
Phone Number 
Business Fax Number 
Departure Date (mm/dd/yyyy) 
Return Date (mm/dd/yyyy) 
Purpose of Travel 

If Other, please specify:

Type of Travel 

If Other, please specify:


If Other, please specify:

Flight Itinerary, Including Airport Stopovers 
Country 1 
City 1 
Duration 1 
Urban/Rural 1 
Country 2 
City 2 
Duration 2 
Urban/Rural 2 
Country 3 
City 3 
Duration 3 
Urban/Rural 3 
Country 4 
City 4 
Duration 4 
Urban/Rural 4 
Medical History 
Primary Care Physician 
Primary Care Physician Phone Number 
List All Allergies (drugs, foods, bites/stings) 
Have You Ever Had a Travel Related Illness? 
If Yes, Please Explain 
Do You Have a History of Any of the Following? 
Heart Rhythm Problem 
Stomach/Colon Problems 
Depression/Psychiatric Problems 
Bleeding Disorder 
Present Medical Conditions 
Surgical History 
Present Medications 
Has Your Spleen Been Removed? 
Do You Have a Condition That is Now Stable but Which May Recur During Travel? 
Please Explain 
Women: Are You Now Pregnant or Considering Becoming Pregnant? 
Dates of Past Immunizations 
Hepatitis A 
Hepatitis B 
Yellow Fever 
Have You Ever Had the Measles (rubella)? 
Have You Ever Fainted or Had an Adverse Reaction to a Vaccine? 
Today's Date  (dd/mm/yyyy)
I Verify That The Above Information Is Correct * 
May We Contact You at the E-mail Address Above? 
If Not, Please Provide Your Contact Information 
By selecting this box and the "Submit" button,
I agree to the Disclaimer and Privacy Policy* 

Authentication * 

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