UT Physicians

UTHealth Houston Epilepsy – Program Referral

Thank you for contacting UTHealth Houston Neurosciences. Please answer these quick questions, and we will get your referral passed on to a Texas Comprehensive Epilepsy Program representative immediately.

Patient Information

Patient's Name:(Required)

First Last

Date of Birth:

Email Address:(Required)

Phone Number:

(Please leave blank if you don't want to be called)

Referring Provider:(Required)

Office Contact Name:(Required)

Office Contact Phone:(Required)

Office Contact Fax:

Referral Reason(Required)

Please indicate the reason for the epilepsy referral request:

Type of Referral(Required)

Office Consultation (May include EMU admission at provider's discretion)

EMU Admission Only (Will be asked to follow up with referring provider)

Outpatient Diagnostic Evaluation Only

Schedule Referral(Required)

Physician-to-Physician Communication(Required)

Would your provider prefer direct communication from our provider after workup or evaluation in EMU?

Please upload related documents here

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB, Max. files: 10.

Important: Fax EEG results to (713) 383-1437. If an EEG has NOT been done in the past three months, please let us know the date; insurance may require a new EEG before more testing.

Terms for Online Appointment Request

The information we collect from this website is used only for obtaining information about you for scheduling purposes.

You and UTHealth Houston Neurosciences do not yet have a patient-provider relationship. The information we collect will be used to contact you because you have requested that we contact you.

In addition, information provided on the website or in any response to you is not and cannot be considered medical advice or treatment.

Name

This field is for validation purposes and should be left unchanged.

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Patient Resources

New Patient?

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Patient Services

1-855-877-2808

Customer Service Hours

8:30 a.m. – 5:00 p.m. CST

Insurance

COVID-19

More

Why UT Physicians?

UTHealth Houston Epilepsy – Program Referral

Patient Information

Terms for Online Appointment Request

888-4UT-DOCS

888-488-3627

UTHealth Houston Professional Building

6410 Fannin Street
Houston, Texas 77030

QUICK LINKS

PATIENT STORIES

© Copyright 2023 – The University of Texas Health Science Center at Houston (UTHealth Houston)

Contact / Feedback | Report Error | Patient Privacy | Web File Viewing | Site Policies | Employee Links

Find a Doctor

Find Locations

Patient Care

Careers

Patient Info

Why UT Physicians

Find a Doctor

Select an area

Patient Care

Adult Health

Children's Health

Women's Health

Patient Resources

New Patient?

Billing

Patient Services

1-855-877-2808

Customer Service Hours

8:30 a.m. – 5:00 p.m. CST

Insurance

COVID-19

More

Why UT Physicians?

UTHealth Houston Epilepsy – Program Referral

Patient Information

Terms for Online Appointment Request

888-4UT-DOCS

888-488-3627

UTHealth Houston Professional Building

6410 Fannin StreetHouston, Texas 77030

QUICK LINKS

PATIENT STORIES

© Copyright 2023 – The University of Texas Health Science Center at Houston (UTHealth Houston)

Contact / Feedback | Report Error | Patient Privacy | Web File Viewing | Site Policies | Employee Links

Find a Doctor

Find Locations

Patient Care

Careers

Patient Info

Why UT Physicians

6410 Fannin Street
Houston, Texas 77030