Request an Appointment


Patient is:
  
First Name:
Last Name:
  
  Click here if Patient's name is same as above
   
Patient's First Name:  
Patient's Last Name:  
   
Is the Patient a UH employee or student? Yes No
 
Please Choose: 
  
Patient's Age:
Patient's Date of Birth:
 (MM/DD/YYYY)
  
Address:
 Apt: 
City:
State:    Zip: 
  
Daytime Phone Number:
Cell / Alternate Phone:
Email Address:
  
Insurance Provider:
  
What type of appointment do you need? (if this is an emergency, please call (713) 743-2010)
  Complete Eye Exam(Glasses)   More Info
Complete Eye Exam(Contact Lenses)   More Info
Complete Eye Exam (Contact Lenses and Glasses)   More Info
Low-Vision Rehabilitation   More Info
Other
Please explain:
Would you like to request a specific Doctor?
Would you like to request a specific Doctor?
Would you like to request a specific Doctor?
Please select a date range for your appointment
  
Start Date
Chosen Dates:
End Date
  
Would you prefer a morning or afternoon appointment?
  Morning (8 a.m. - Noon)
Afternoon (1 - 5 p.m.)
No Preference
  
How did you hear about us:
  
Web Address or Name:   
  
  
Where did you hear about us?   
  
 
Once your request is recieved you will be contacted to schedule your appointment.