New Page | Houston Specialty Clinic

top of page

Houston Specialty Clinic

Pediatric Neurology, Pediatric Pulmonology, and Sleep Medicine

Houston, Sugar Land, and Telehealth

HOME
ABOUT US
- OUR TEAM
  JOSHUA S. ROTENBERG MD
  SARAT C. SUSARLA MD
  KARA SCHMIDT PA-C
  AMEE MORENO DNP
  SHAMILE MORGAN LCC
- OUR LOCATIONS
SERVICES
PATIENT INFO
- PATIENT PORTAL
- STEPS TO BECOME A NEW PATIENT
APPOINTMENTS
OUR BLOG

PATIENT PORTAL

MAKE A PAYMENT

CONTACT US

Appointment Request Form

Please fill out the details in the form below to submit a new appointment request for Houston Specialty Clinic.

DISCLAIMER: If you are experiencing a medical emergency, please call 9-1-1. This form is for appointment requests only.

Referring Provider Details

Referring provider name (if applicable)

Reason for appointment

Urgency

First name

Patient Contact Information

Middle name

Last name

Suffix

Date of birth * required

Sex *

Male

Female

Street address

Zip code

City

State

Email

Phone number

Phone type

Is the Patient a Minor? *

Yes

No

Parent/Guardian Name (If the Patient is a Minor)

Parent/Guardian Relationship

Parent/Guardian Phone number

Parent/Guardian Email

Guarantor's Information

Guarantor's name

Guarantor's phone number

Guarantor's date of birth

Guarantor's address

Insurance company

Patient Insurance

Policy ID Number

Group number

Is the patient the insurance holder? *

Yes

No

Policy holder's first name (If you answered no to previous question)

Policy holder's middle name

Policy holder's last name

Policy holder's suffix

Policy holder's date of birth

Policy holder's sex

Male

Female

Patient's relationship to policy holder

Do you have secondary insurance? *

Yes

No

Secondary insurance name

Secondary insurance policy number

Secondary insurance group number

Appointment Preferences

Preferred location

Provider to see

Preferred day of week

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred time of day

Morning

Evening

Afternoon

Thanks for submitting!

Houston Specialty Clinic, Houston, TX

713-464-4107

Fax 713-465-4522

902 Frostwood Drive, Suite 210

Houston, TX 77024

Houston Specialty Clinic, Sugar Land

713-464-4107

Fax 713-465-4522

1111 HWY 6, Suite 100,

Sugar Land, TX 77478

Privacy Policy

Houston Specialty Clinic

Sleep & EEG Center

713-395-0470
7505 Fannin St, Suite 425,

Houston, TX 77054

Terms & Conditions

bottom of page