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 * 
Address2 
City * 
State * 
Zip Code * 
Country 
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 
Relationship 
Business Information 
Employer 
Occupation 
Phone Number 
Business Fax Number 
Itinerary 
Departure Date (mm/dd/yyyy) 
Return Date (mm/dd/yyyy) 
Purpose of Travel 

If Other, please specify:

Type of Travel 

If Other, please specify:

Accommodations 

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 
Seizure/Epilepsy 
Stomach/Colon Problems 
Depression/Psychiatric Problems 
Bleeding Disorder 
Nightmares 
Psoriasis 
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 
MMR 
Tetanus/Diphtheria 
Influenza 
Polio 
Typhoid 
Hepatitis B 
Yellow Fever 
Pneumovax 
Other 
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 
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I agree to the Disclaimer and Privacy Policy* 

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