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 Year1924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026 Year Legal Sex * -Select-MaleFemale Mobile Number * Reason for Visit * How Long Until Your Arrive? * -Select Time Slot-8:15 pm - 05/05/2021 Have you been treated at any UT Health East Texas facility before? * - Select -YesNo Leave this field blank Submit