UTMB > For Patients & Visitors > Patient Forms

Request an Appointment

Are you a Current Patient?

Save time and effort by using MyChart to request or reschedule your appointment, see your records and results, communicate with your doctors and request Rx refills.

UTMB Health My Chart - click for more information

Are you a New Patient?

Welcome! To request a new appointment, please complete the form below. Fields marked with an * are required, and information provided via this form is secure. Once you have submitted your information, you will receive a call or email with your appointment details within two business days.

UTMB My Chart Log On

New Patient Appointmets


Online Appointment Request form for New Patients or patients without access to MyChart

Please review these important tips before getting started:

For your security and privacy, your information will not be saved if you browse away from this page. If you have questions about this form or need assistance, please contact the Access Center.


  Do you have a particular physician that you would like to see?

If yes, please enter that physician's name here:

Patient Information
 *
 *
 *
   
Birth Date: *   
Marital Status: *
 *
 *
State: *
Zip Code: *
Day Telephone: *
Evening Telephone:

Contact Information
Relation:
Contact's Telephone:
Email Address: *

Insurance Information
Primary Health Insurance
Name: *
 Notice
Note: if you chose "none" for your health insurance name, the remaining fields in "insurance information" are not required
Primary Health Insurance
Type: *
Policy #: *  
Group #: *  
Primary Holder: *  

Appointment Information
Primary Care Provider or Referring Physician's Name:
 
Have you ever had an appointment at UTMB? *

Have you seen this physician before?

Type of service
requested: *
Reason for appointment: *  

Time Preference
Day of week: * or
Time of day: *
Additional comments:  
You should have a response within two business days. For additional questions about your appointment, please call the UTMB Access Center at 1-800-917-8906.

 

 


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Call for assistance day or night 409-772-2222

Insurance

Which insurance plans do we accept? See the list of common ones, and please contact us if you don't see yours.


Online Referrals

Need to reschedule or cancel? Use our Appointment Reschedule Request Form.

Need to request a prescription refill? Use our Rx refill request.

 
 

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