Submitted by ahs-admin on Tue, 11/24/2020 - 11:48 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? * -Select Time Slot-2:00 pm - 02/22/20252:30 pm - 02/22/20253:00 pm - 02/22/20253:30 pm - 02/22/20254:00 pm - 02/22/20254:30 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 - 02/22/2025 Have you been treated at any UT Health East Texas facility before? * - Select -YesNo Leave this field blank Submit
