Refer a Patient to the Houston Methodist Lung Center

This form is for physicians referring patients only. If you are a patient, please complete this Houston Methodist Lung Center - Patient Request an Appointment form instead.

The Houston Methodist Lung Center evaluates patients with a wide variety of breathing disorders, from the common to the complex.

• Every effort will be made to contact your patient within 2 business days to schedule an appointment.
• If you would like to schedule an appointment over the phone you can call us directly at 713.441.7779.
• Completing and submitting this form to the Houston Methodist Lung Center does not guarantee an appointment was made.
• Please fax relevant patient medical records to 713.796.1701.

Patient Information

First Name * Last Name * Caregiver's Name Gender * Male Female Prefer not to answer Date of birth * Address 1 * Address 2 City * 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 ZIP code * Phone Number * Email Address * Medications Patient's Medical Concerns (please include ICD-9 codes if known) *

Physician Information

Physician Name (if applicable) Address Phone Number Fax Number Email Address (referring physicians must provide an email address) * How did you hear about the Houston Methodist Lung Center?

Authentication *