Please fill out the details in the form below to submit a new appointment request for Central Texas Surgical Associates

DISCLAIMER: If you are experiencing a medical emergency, please call 9-1-1. This form is for appointment requests only.

Referring provider name (if applicable)

Reason for appointment
—Please choose an option—AbscessesAppendicitisBariatricColon TumorsDiverticulitisGallbladderGERDHerniasLipomasMelanomaPeptic Ulcer DiseaseSkin LesionsSmall Bowel ObstructionTumors or Cysts
Additional Details

Urgency
—Please choose an option—EmergentRoutineUrgent
First name

Middle name

Last name

Suffix

Date of birth

Gender
—Please choose an option—MaleFemale
Street address

Zip code

City

State
—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Email

Phone number

Phone type
HomeMobileWork
Insurance company
—Please choose an option—No insuranceNot listedAETNABlue Cross Blue ShieldCIGNAFirst HealthGEHAGolden RuleHumanaMedicarePrivate Health Care System Network (PHCS)The MultiPlan NetworkPrivate Health Care System Network (PHCS)TriCareUnited Healthcare
Policy ID Number

Policy Group Number

Is the patient the insurance holder?
YesNo
Is an insurance referral required?
YesNo
Preferred location
—Please choose an option—Any, first availableRound RockMcKinneyFlower Mound
Provider to see
—Please choose an option—Any, first availableAndy L Hawthorne, MDBratcher L Runyan, MDMario A Longoria, MDWade W. Dunlap, MDJames P. Carroll, MDChad E. Treece, MDColin L. Doyle, MD
Preferred day of week
—Please choose an option—Any, first availableMondayTuesdayWednesdayThursdayFriday
Preferred time of day
—Please choose an option—Any, first availableMorningAfternoon