CACNA1A Center Appointment Request

Patient Information

Please provide the best number to reach you at for health-related matters.

Insurance Information

Genetic Testing Report

This information is necessary to assess the patient's eligibility for our clinic. If you do not have a copy of the genetic testing report, please contact your healthcare provider to obtain it before submitting your appointment request.
Accepted file types: pdf, jpg, gif, png, Max. file size: 20 MB.
Terms for Online Appointment

The information we collect from the online form is used only for appointment scheduling purposes. Any follow up phone calls or email communications will be related to your care.

You and UT Physicians or any of its health care providers do not have a patient-provider relationship.

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

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