Please complete as much of the form below prior to your scheduled appointment with Employee Health Services at UTHealth Houston.

CONFIDENTIALITY STATEMENT: Employee Health Services at UTHealth Houston requires you to provide personal health information protected by University policy and State and Federal law. Your information will be used or disclosed in accordance with those policies and laws only to the minimal extent necessary for your treatment or for business operations. Your rights to the confidentiality of your personal health information will be strictly maintained by Employee Health Services. The information contained within the form below will be stored electronically at Employee Health Services. If it is required for your role, please attach pertinent documentation or laboratory report(s) at the end of the form. PDF version of attachments is preferred. Required fields are marked with a *.