Houston Methodist. Leading Medicine.
Houston Methodist. Leading Medicine

Request an Appointment

Request an Appointment

To request an appointment, please contact 713-790-3333 or complete the form below. If you submit a form, a representative will contact you by the next business day to confirm or discuss your request. Filling out this form does not guarantee that an appointment is scheduled. If you would like to schedule an appointment within the next 24 hours, please contact us at the phone number above to ensure you receive a prompt reply.

To protect your privacy, our online forms are encrypted and stored in a secure location; however any communication via e-mail may not be, so please consider that when selecting a way for us to contact you.

* Indicates required information
Patient's First Name * 
Patient's Middle Initial 
Patient's Last Name * 
Patient's Address1 * 
Patient's Address2 
City * 
State * 
Zip Code * 
Country 
Daytime Phone Number * 
Evening Phone Number 
Patient's E-mail Address * 
Date Of Birth * 
Patient's Social Security Number (If none, enter, 888-88-8888) * 
Gender 
Health Insurance Plan Name * 
Health Insurance Type 
Insured's Name * 
Insured's Social Security Number * 
Insured's Subscriber or Member ID Number * 
Insured's Home Phone Number 
Insured's Work Phone Number 
Insured's Date of Birth *  (dd/mm/yyyy)
Employer Name * 
Employer Group Number * 
Verification/Customer Service Phone Number * 
Your Name (if different from patient) 
Your e-mail Address (if different from patient) 
Your daytime Phone Number (if different from patient) 
Relationship to Patient 
Is There a Specific Doctor You're Requesting? 
If Yes, Please Provide Name 
Patient Status with This Doctor 
Specialty Preference * 
Reason for Appointment
(Please provide as much detail as possible
to assist us in referring you to an appropriate physician) * 
Appointment Preference 
Location Preference * 
Day of the Week 
Time of Day 
When 
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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