Houston Methodist J.C. Walter Jr. Transplant Center Patient Form

Patients of Houston Methodist J.C. Walter Jr. Transplant Center have access to state-of-the-art resources at Houston Methodist Hospital in the Texas Medical Center. To learn more about our advanced organ failure management and transplant services, expert physicians or to seek treatment, complete the form below. A representative will contact you within two business days.

En Español

Patient First Name * Patient Middle Initial Patient Last Name * Patient Address * Patient City * Patient State * AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Patient Postal Code * Patient Email Address * Patient Daytime Phone * Patient Date of Birth * Transplant Center Clinic or Program * Advanced heart failure Heart transplant Kidney transplant Liver disease Liver transplant Lung transplant LVAD (mechanical circulatory support) Pancreas transplant Heart Tumor Program Islet transplant Bone marrow transplant Multi-organ transplant Amyloidosis Intestinal failure treatment Living donation Advanced Lung Disease Other If Other Clinic or Program, please specify Insurance Provider Aetna Blue Cross and Blue Shield of Texas Cigna Healthcare of Texas Crown Health Services First Health (Coventry Members) Humana Kelsey-Seybold PHCS/MultiPlan Texan Plus HAA Preferred Partner/AHA Assistance USA PPO Medicus PPO Olympus PPO Interlink Health Service Cigna LifeSource Optum Health LifeTrac United Healthcare U.S. Family Health Plan Traditional Medicare Traditional Medicaid Other If Other Insurance Provider, please specify Best day/time for staff to call you Monday – Friday, 8 a.m. – 4:30 p.m. Comments I would like to stay connected with Houston Methodist on upcoming events, health tips and newsletters. Yes

Authentication *