Submitted by ahs-admin on Fri, 03/26/2021 - 09:01 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 Year1921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 Year Legal Sex * -Select-MaleFemale Mobile Number * Reason for Visit * How Long Until Your Arrive? * -Select Time Slot-12:30 pm - 04/08/2021 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. Submit
