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 up to 2 business days for your appointment request to be processed and the outcome communicated to you via email.
  • Please be aware, submitting this form does not guarantee your appointment is scheduled.

Appointment Information

Step 1 of
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 *
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? *
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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