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Online Physician Request
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Online Physician Request
This form is not intended to be used in emergency situations. If you are uncertain of the urgency of your problem, contact your personal physician or the nearest hospital for assistance.

Our experts will help you select a physician and schedule an appointment with the right physician who accepts your insurance. To contact us, complete the form below or call 713-442-0427. We will respond to your request within two business days during normal business hours (7:30 a.m. - 5:00 p.m. CST). Kelsey-Seybold does not charge a fee to you or to our physicians for this service. If you believe you are experiencing a medical emergency, please seek help immediately from your physician or from a local emergency care center.

Note: ** indicates required field.

Your Name: ** ( First      MI          Last ) Relationship to Patient: ** 
Patient's Name: ** ( First      MI          Last ) Patient's Date of Birth (m/dd/yy): ** 
Country: ** Zip Code: **
Type of Insurance: **
Best Time to Contact: ** Type of Specialist Requested: **
Preferred method of contact: ** Telephone: **
Do you prefer a male or female physician? ** What is your language preference? **
Pick an area of town to see a Kelsey physician: **  
 
How did you hear about Us? ** E-mail: ** 
Comments:
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Kelsey-Seybold respects the confidentiality of your personal information and promises only to use it for internal purposes as it relates to this request. If you are uncertain about transmitting this information over the Internet, select the Reset Form button. You may call Kelsey-Seybold at 713-442-0427 during normal business hours: 7:30 AM to 5:00 PM CST Monday through Friday.
 
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The health information contained on this website is for educational purposes only and does not constitute medical advice or a guaranty of treatment, outcome, or cure. Please consult with your healthcare provider for specific medical advice. This information is not intended to create a physician-patient relationship between Kelsey-Seybold Clinic or any physician and the reader.

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