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Athletic Trainer Appointment Form

This *ALL NEW* section is specifically designed to assist Athletic Trainers in notifying our office of injuries and to request an initial appointment availability.  This is ONLY for Licensed and/or Certified Athletic Trainers who work directly with high school teams in the Greater Houston area, colleges and universities as well as other professional teams.
 
This request will go directly to our Licensed Athletic Trainers on staff.  They can then designate and notify our office to help streamline the care of your injured athlete.

Name of Athletic Trainer:*
Name of School:*
Level of Sport:*
Athletic Trainer E-Mail:*
Athletic Trainer Contact Number:*
The Athletic Trainer will be contacted using the telephone number you provide. Text messages are sometimes more efficient for more timely correspondance once request is submitted.
What type of contact telephone number is this?
Please briefly describe the injury, mechanism, and your clinical finding:*
Please be as specific as you can. This will assist us in fast-tracking your request. Please include mechanism of injury, your clinical evaluation of the athlete and any necessary finding, swelling, etc.
Primary Insurance Carrier of Athlete:*
Example: Blue Cross / Blue Shield of Texas PPO
Secondary Insurance Carrier (School Insurance):*
If athlete is not covered under school insurance, type "None".

For security reasons,

type in the code below:

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Memorial Hermann Sports Medicine Institute

In affiliation with
The University of Texas Medical School
& UT Physicians
Memorial Hermann Medical Plaza
6400 Fannin, Suite 1700
Houston, TX 77030
TEL: (713) 486-6540 Option 1
FAX: (713) 512-7235
(Clinic on TUESDAYS only)

 

Satellite Clinic Location
** NEW LOCATION **
17510 W. Grand Parkway South
Suite 450
Sugar Land, TX 77479
TEL: (713) 486-6540 Option 2
FAX: (713) 512-7235
(Clinic on MONDAYS only)

Medical Center University of Texas Health Science Center at Houston

ACADEMIC OFFICE INFORMATION
Edward T. Smith Professor & Chair
Department of Orthopaedic Surgery
University of Texas Medical School at Houston
6431 Fannin
Medical School Building, 6.156
Houston, TX 77030