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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 within three business days.

First name *
Middle initial
Last name *
Country *
Address *
Apartment/Unit
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State
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Daytime phone number *
Evening phone number
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Date of birth *
Please choose "Yes" to at least one of the five questions below
Do you have a question pertaining to your bill? *
Account number *
Date of service at Houston Methodist *
Health insurance plan *
Physician *
Reason for stay/visit *
Your name (if different from patient)
Billing question *
Are you contacting us regarding your stay at Houston Methodist? *
Hospital location *
Physician *
Reason for stay *
Your name (if different from patient)
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Would you like to provide patient or guest feedback? *
Are you the patient? *
Patient's first name *
Patient's last name *
Patient's date of birth *
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Comments / Question *
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Do you have a question about our website? *
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Provide link to page if applicable
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Is your question regarding a hospital location? If so, which hospital?
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I would like to stay connected with Houston Methodist on upcoming events, health tips and newsletters.
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