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Request an Appointment with a Doctor

  • The submission of this form allows the Houston Methodist Physician Referral Services Center to facilitate your appointment request. We will share the information you provide here with the provider’s office.
  • Please allow approximately one week for your appointment request to be processed and the outcome communicated to you via email due to the holidays and high volumes we are experiencing.  For faster assistance, you may contact the physician’s office directly to be scheduled or call 713.790.3333 for assistance in locating a doctor.
  • Please be aware, submitting this form does not guarantee your appointment is scheduled.

Appointment Information

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Is there a specific doctor you're requesting? *
If yes, please provide the doctor's first name, last name or both. * (Please note: If the name entered isn't found, please call the doctor's office directly to schedule an appointment.)
What specific medical specialty are you requesting? If you don't know, then write 'unsure.' *
Please describe the reason for your visit in detail, so that we can schedule you appropriately. *
Please indicate the preferred area of town (Sugar Land, Katy, Medical Center, etc.) or ZIP code for your appointment and we will try to accommodate if available. *
Appointment preferences (i.e.: day, time, language, provider gender, etc.). While we will do our best to accommodate any preferences, please understand this may not always be possible.
Country of residence *
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Patient's first name *
Patient's middle name
Patient's last name *
Date of birth *
Patient's gender *
Are you pregnant? *
Last menstrual cycle start date *
Patient's address *
Apartment/Unit
City *
State *
Postal code *
City code *
Country code *
Mobile phone number *
Alternate phone number
Email address *
Confirm email address *
Are you the patient? *
Your name *
Your phone number *
Your email address *
Country of residence *
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? *
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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 *
Do you have additional/secondary insurance coverage? *
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 *
How did you hear about us? *
If Other, please specify *
Name of referring physician
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While the information in this form is encrypted and stored in a secure location, Houston Methodist’s email responses are unencrypted, posing a risk of disclosure if  misdirected or accessed by a third party. If you prefer not to receive a reply via unencrypted email, please contact us at 713.790.3333 between 7 a.m. and 6:30 p.m., Monday through Friday. Or, please call the desired doctor’s office at the phone number listed on his or her profile.

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