CPAM - Request an Appointment

To request an appointment, please contact 713.394.6088 or complete the form below. If you submit a form, a representative will contact you within 1-2 business days to confirm or discuss your request.

 

*denotes required field

Patient Information

Patient's First Name * Patient's Middle Initial Patient's Last Name * Patient's Address 1 * Patient's Address 2 City * 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 ZIP Code * Country Daytime Phone * Evening Phone Patient's Email Address * Date of Birth * Patient's Social Security Number (If none, enter, 888-88-8888) * Gender Male Female Health Insurance Plan Name Health Insurance Type EPO HMO Medicaid HMO Medicare Other POS PPO 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 Email Address (if different from patient) Your daytime Phone Number (if different from patient) Emergency Contact Phone Number

Is There a Specific Doctor You're Requesting?

Yes No

If Yes, Please Provide Name Patient Status with This Doctor New Established Specialty Preference Reason for Appointment

Appointment Preference

Day of the Week Any Monday Tuesday Wednesday Thursday Friday Time of Day Any Morning Afternoon When First Available One Week Two Weeks Three Weeks How Did You Find Out About Us? * Houston Ballet Astros Baseball Game Texan Football Game Billboard Brochure/Flyer Direct Mail/Invitation Internet Magazine Houston Chronicle Doctor Nurse Family Friend Other

May We Contact You at the Patient's E-mail Address Above? *

Yes No

If Not, Please Provide Your Contact Information

I would like to stay connected with Houston Methodist on upcoming events, health tips and newsletters.

Yes

Additional Information

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