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Appointment Request – Adult Epilepsy

Thank you for contacting UT Physicians Adult Epilepsy. Please fill out this short list of questions, and we will get back to you as soon as possible.
Please provide the potential patient's name:(Required)
(Please leave blank if you don't want to be called)
If you do want a callback, what is the best time of day to call you?(Required)
Insurance Type (This helps us best route your form)(Required)
(Preferred physician or type of physician, location preference, other information about how we can best help you)

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 / UT Physicians 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.

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