Houston Methodist Partners - Request an Appointment

Employees of our corporate partners may request an appointment with a Houston Methodist doctor by completing this form.

• A representative will contact you by the next business day to discuss your appointment request.
• Please be aware, submitting this form does not guarantee your appointment is scheduled.
• To protect your privacy, all of our online forms are encrypted.

Appointment Information

Is there a specific doctor you are requesting? *

Yes No

If Yes, please provide name of doctor Patient status with this doctor New patient Established patient If no specific doctor, do you prefer a female or male doctor? Female Male No preference Specialty preference(s) * Reason for appointment *

Patient Information

Patient first name * Patient middle name Patient last name * Patient address Patient address 2 Patient city Patient state AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Patient ZIP code Patient date of birth *

Patient gender *

Female Male Unknown

Are you the patient? *

Yes No

Contact email address * Contact phone * Company name *

Insurance and Additional Information

Health insurance plan name * Health insurance type * PPO EPO POS HMO Medicaid Medicare Other Member insurance ID number * Insurance Group number

Is the patient the primary subscriber? *

Yes No

If, no, primary subscriber's first and last name Primary subscriber's date of birth Primary subscriber's gender Female Male Unknown Primary subscriber's relationship to patient Spouse Mother Father Other Additional information, if any

Authentication *