UTMB > For Patients & Visitors > Patient Forms

Online Appointment Form

To request a new appointment, please complete the form below. All fields marked with an * are required. Information provided via this form is submitted in a secure environment. Once you have submitted your information, you will receive a call or email with your appointment information within two business days.

Please review these important tips before getting started:

  • This appointment request service is not intended for urgent or emergency situations. Please contact your physician's office directly, contact the Access Center or dial 911.
  • If you already have a current appointment and need to reschedule or cancel, please use our Appointment Reschedule Request Form.
  • Need to request a prescription refill? We have a form specifically for Rx refills.
  • If you need to schedule more than one appointment, please make only one request per form submission. (Submit one form per appointment request)
  • For Behavioral Health services in Psychiatry, online appointments are not available. Please call (409) 772-0770 or 1 (800) 917-8906 ext. 20770 for assistance.
  • Are you a current patient? Save time and effort by using MyChart to request your appointment. [more information]

Please be aware your information will not be saved if you browse away from this page while filling out form. 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.

 

 


Copyright © 2001-2012 The University of Texas Medical Branch.
Please review our privacy policy and Internet guidelines. Send email to UTMB with questions or comments about this web page.

 

Call for assistance day or night 409-772-2222

Online Referrals

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

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

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

Are you a current patient? Save time and effort by using MyChart to request your appointment.

MyChart information

 
 

Support UTMB | For UTMB Employees | Site Index | Privacy Policy | Required Links | Contact Us

Copyright © 2014 The University of Texas Medical Branch • Member, Texas Medical Center ®
Managed by UTMB Health Marketing and Communications. Contact us.
301 University Blvd., Galveston, TX 77555-0144