Request An Appointment


Please complete the form below, and allow up to two business days for your request to be processed. If you would like to schedule an appointment sooner, please call your doctor’s office. Once we receive your request, we will schedule your appointment and send you an email confirmation. We may contact you if we have questions about your request. Please be aware that submitting this form does not guarantee your appointment is scheduled.

To protect your privacy, all of our online forms are encrypted and stored in a secure location. However, while our forms are secure, communication via email may not be. If you prefer not to receive communications via email, please contact us at 713.790.3333 for assistance with scheduling an appointment. Our team is available from 7 a.m. to 6:30 p.m., Monday through Friday.

Patient Information
Patient's first name *
Patient's middle name
Patient's last name *
Country *
Patient's address *
Apartment/Unit
City *
State
Postal code *
City code *
Country code *
Phone number *
Email address *
Confirm email address *
Date of birth (MM/DD/YYYY) *
Patient's gender *
Are you the patient? *
Your name *
Your phone number*
Country *
Your email address *
Your relationship to the patient *
What is your diagnosis? *
What date would you like the appointment *
Are you a self-paying
patient? *
Do you have health insurance? *
If yes what is the name of your insurance?*
Have you notified your insurance of this consult/procedure? *

Insurance Information
Health insurance plan
name *
Health insurance type *
Member ID number *
Group number
Insurance's customer service phone number
Is the patient the subscriber? *
Name of the subscriber *
Relationship to patient *
Subscriber Date of birth (MM/DD/YYYY) *
Employer name *

Appointment Preference
Is there a specific doctor you're requesting? *
If yes, please provide
name *
Please describe the type of doctor you need and the issue you are experiencing *
Location preference *
Appointment preferences
I would like to stay connected with Houston Methodist on upcoming events, health tips and newsletters.
How did you hear about
us? *
If Other, please specify *
Authentication *
*