ER, Acute Care, Walk In Appointment Request
Attention Walk-In Emergency Care Administrators:  We have developed this email portal directly for your team to refer orthopedic cases more efficiently.  Please enter the basic information below and the OrthoTexas team will coordinate scheduling with the patient immediately.  Our care teams will provide notes and keep your teams informed on the progression of the patients recovery.  We appreciate your support and will be an excellent partner to your fast-paced, community care facility.  

All patients entered into this form will usually be contacted with two (2) hours if received prior to 4:00 p.m. Monday through Friday.  If received after 4:00 p.m. Friday to Monday before 8:00 a.m., you will be contacted by 10:00 a.m. on Monday.     
Thank You
ER, Acute Care, Walk In Appointment Request *required information
Clinic Name *
Patient Name *
Patient Address(city only)*
Patient Phone Number*
Patient Email*
Request Type*
Is the Patient Insured*
Patient Insurance Carrier*
Overview of Injury*
Enter Code Shown Below *

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