Get an Update on your Patient

If you are an EMS responder, you can use this form to securely request an update on the condition of a patient that was in your care and delivered to a UTMB site. This form is ONLY for EMS personnel; general patient information inquiries should be directed at (409) 772-1011.

Patient Name

Patient Date of Birth (DOB)

Date of Service (DOS)

Services provided at:

Taken to UTMB for

Medic's Name (first and last)

EMS Agency

Medic's Phone Number

Medic's Work Email Address