UTHealth School of Dentistry Appointment Request

Online Appointment Request Form

This form is for standard appointment requests only.
For a dental-emergency appointment, please call 713-486-4000 and choose option "1".
If you are experiencing a life-threatening emergency, please call 9-1-1 or visit the closest Emergency Room.

Please allow for a two business day turnaround for requests received Monday through Friday.
Requests received on weekends or holidays will receive a response within two business days after the start of business the following week.

Level of Care Requested

Note: Student Clinic Appointment Requests (Age 18+, 1/3 private cost) are made available during limited times throughout the year.

Reason ^⁢*

Invalid reason for appointment.

Availability

Note: Selecting multiple time slots allows us to best accommodate your request

Select All

Monday AM

Monday PM

Tuesday AM

Tuesday PM

Wednesday AM

Wednesday PM

Thursday AM

Thursday PM

Friday AM

Friday PM

Other

Are you a new patient? ^⁢*

Invalid input.

Are you being referred by an outside doctor? Please explain:

Invalid input.

Are you currently a Veteran? ^⁢*

Invalid input.

Name and Demographics

First Name ^⁢*

Invalid input.

Last Name ^⁢*

Invalid input.

Preferred Name ^⁢*

Invalid input.

Gender ^⁢*

Invalid input.

Birth Date^⁢*

Invalid input.

Preferred Language ^⁢*

Invalid input.

Race

Ethnicity

Invalid input.

I decline to answer questions about ethnicity and race

Contact

Phone Type ^⁢*

Invalid input.

Phone Number ^⁢*

Invalid phone number.

Email ^⁢*

Invalid email.

Address ^⁢*

Invalid input.

Address 2

Invalid input.

Country ^⁢*

Invalid input.

State/Province ^⁢*

Invalid input.

City ^⁢*

Invalid input.

ZIP/Postal Code ^⁢*

Invalid input.

Insurance

Insurance Coverage ^⁢*

YesNo

Invalid input.

Primary Insurance Company

Invalid input.

Group #

Invalid input.

Subscriber ID

Invalid input.