Endocrine Surgery / Appointment Request

Patient Contact Information
Patient Name*

First NameLast Name
Contact name if not patient

First NameLast Name
Phone Number*

Area CodePhone Number
Date of Birth
Month*
Date*
Year*
Appointment Questions
Do you need to see doctor for: (Check all that apply.)*

Hyperthyroidism (too much thyroid hormone, ie Graves’ disease or overactive thyroid nodule(s))Hypothyroidism (you need to see a doctor to prescribe thyroid hormone pills because your thyroid function is too low)A Thyroid nodule or thyroid mass was found on examination and needs to be evaluatedPossible high blood calciumOther
If you need to be seen for a thyroid nodule, do you already have an ultrasound?

YesNo
Has the nodule already been biopsied?

YesNo
Do you have an endocrinologist?*

NoYes
If you have an endocrinologist, provide their Name and Phone Number.
Appointment Request
Are you a current Baylor Medicine Patient?*

YesNo
Best Time to Call*

Morning (8 a.m. - Noon)Afternoon (Noon - 5 p.m.)
Preferred physician or specialty
Insurance Company Name
Preferred appointment times

Monday morningMonday afternoonTuesday mondayTuesday afternoonWednesday morningWednesday morningThursday morningThursday morningFriday morningFriday afternoon
Reason for visit
Should be Empty:

Patient Contact Information