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UTHealth Houston COVID-19 Center of Excellence Referral

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Name*
MM slash DD slash YYYY
Parent / Guardian Name
If patient is aged 17 or under, please provide parent / legal guardian phone number.
If patient is aged 17 or under, please provide parent / legal guardian email address.
Referring Physician Name*
UT Physicians uses Transport Layer Security (TLS) encryption (also known as HTTPS) for all transmitted data. We also protect all individual internal form data with passwords. Our data is hosted by data centers that are SSAE-16 SOC II certified. To request a free copy of our latest UT Physicians Resource Guide for Referring Physicians, please contact us.
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