Submitted by ahs-admin on Tue, 11/24/2020 - 12:44 You must have JavaScript enabled to use this form. If you have chest pain, bad stomach pain, trouble breathing or think you may be having a stroke, call 911 or go to the nearest emergency room. First Name * Last Name * Date of Birth * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year1925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027 Year Legal Sex * -Select-MaleFemale Mobile Number * Reason for Visit * How Long Until Your Arrive? * 4:30 pm - 02/22/20255:00 pm - 02/22/20255:30 pm - 02/22/20256:00 pm - 02/22/20256:30 pm - 02/22/20257:00 pm - 02/22/20257:30 pm - 02/22/20258:00 pm - 02/22/20258:30 pm - 02/22/20259:00 pm - 02/22/20259:30 pm - 02/22/202510:00 pm - 02/22/202510:30 pm - 02/22/202511:00 pm - 02/22/202511:30 pm - 02/22/202512:00 am - 02/23/202512:30 am - 02/23/2025 Have you been treated at any UT Health East Texas facility in the past 2 years? * - Select -YesNo We do our best to meet your requested time, however patients are treated based on severity. Thank you for your understanding and if you have any questions please ask the ER staff. Leave this field blank Submit
