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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)
MM slash DD slash YYYY
(Please leave blank if you don't want to be called)
Please indicate the reason for the epilepsy referral request:
Would your provider prefer direct communication from our provider after workup or evaluation in EMU?
Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.

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.

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