Houston Methodist Lung Center – Patient Request an Appointment

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

• Allow up to two business days (longer for holidays) for us to contact you
• 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 does not guarantee an appointment was made
• If possible, please fax your patient medical records to 713.796.1701

 

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Patient Information

Patient’s first name * Patient's Middle Initial Patient’s last name * Caregiver's Name Patient’s address * 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 NA Postal Code * Daytime phone number * Patient’s date of birth * Email address * Patient’s gender * Male Female Prefer not to answer Insurance provider How would you prefer to be contacted Email Phone

Appointment Information

Please describe the issue(s) and/or symptoms you are experiencing * Please list your current medications Appointment preferences (day/time)

How did you hear about Houston Methodist Lung Center Doctor/Medical Professional Family/Friend Mailer Email Social Media Insurance Company Other I would like to stay connected with Houston Methodist on upcoming events, health tips and newsletters Yes

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