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First name *
Middle initial
Last name *
Country *
Address *
Apartment/Unit
City *
State
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City code *
Country code *
Daytime phone number *
Evening phone number
Email address *
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Preferred way we contact you *


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)
Comments / Questions *
Would you like to provide patient or guest feedback? *
Hospital location *
Comments / Question *
Date of service *
Department that provided service *
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Do you have a question about our website? *
Comments/Questions *
Provide link to page if applicable
Do you have a general question? *
Is your question regarding a hospital location? If so, which hospital?
Comments/Questions *
Would you like someone to contact you? *
I would like to stay connected with Houston Methodist on upcoming events, health tips and newsletters.
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