Houston Methodist. Leading Medicine.
Houston Methodist. Leading Medicine

Email Forms Manager

We are honored that you have selected our expert team of board certified cardiologists and health care professionals to provide you with personalized cardiac care.

To better serve you, please complete this form and our appointment scheduling representative will contact you within one business day. If you prefer to contact us directly, please call 713-441-1100 (Texas Medical Center), 713-441-9909 (Pearland) or toll free at 888-361-4375. We look forward to providing for your cardiac health care needs.

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.

* Indicates required information
Patient's first name * 
Patient's last name * 
Patient's address 1 * 
Patient's address 2 
City * 
State * 
Zip code * 
Country label 
Daytime phone number * 
Evening/mobile phone 
Patient's e-mail address * 
Date of birth *  (dd/mm/yyyy)
Patient's social security number (if none, enter 888-88-8888) * 
Gender * 
Health Insurance Plan Name * 
Health Insurance Type * 

If Other, please specify:

Insured's Name * 
Insured's Social Security Number or ID Number * 
Insured's Home Phone Number 
Insured's Work Phone Number 
Employer Name 
Employer Group Number 
Verification/Customer Service Number * 
Your Name (if different from patient) 
Your e-mail Address (if different from patient) 
Your daytime Phone Number (if different from patient) 
Emergency Contact Name * 
Emergency Contact Phone Number * 
Primary Care Provider 
Please Specify the Office Location for Your Appointment * 
Is There a Specific Doctor You're Requesting? * 
If Yes, Please Provide Name 
Patient Status with This Doctor 
Specialty Preference 

If Other, please specify:

Reason for Appointment 
How soon would you like your appointment? * 
How Did You Find Out About Us? * 

If Other, please specify:

May We Contact You at the Patient's E-mail Address Above? * 
If Not, Please Provide Your Contact Information 
Additional Information 
By selecting this box and the "Submit" button,
I agree to the Disclaimer and Privacy Policy* 

Authentication * 

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