Methodist Service Request

SERVICE WORK REQUEST

HOUSTON METHODIST HOSPITAL LOCATIONS
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TYPE OF REQUEST:*
Please note that all service tasks are performed and billed via T&M. If a quote is needed first then it will need approval prior to work starting. If quote has already been provided please reference it.
Today's date:*

MonthDayYear
Date
PRIORITY LEVEL:

EMERGENCYNEXT AVAILABLEFIRST AMTHIS WEEKLOW
PREFERRED TIME FOR INSTALLATION (Helps with scheduling):*

ANYTIMEMORNINGAFTERNOONAFTERHOURS ONLYSPECIFIC DAY & TIMEOther
Who is requesting the work?
Requested By:*

First NameLast Name
Phone Number:*
E-mail:*
example@example.com
DEPT. ID NUMBER:
(For your internal & tracking purposes)
CG NUMBER:
(For your tracking purposes)
REFERENCE QUOTE:
(Will be displayed on invoice)
REFERENCE PO:
(Will be displayed on invoice)
Who is the onsite contact?
Is onsite contact the same as requester?

YesNo
Onsite Contact:

First NameLast Name
Phone Number:
E-mail:
Who is approving this request?
Director or manager approving the request:*

First NameLast Name
Phone Number:*
Dept. Manager:*

First NameLast Name
E-mail:*
Who is to receive the invoice?
Send invoice to director for processing?

YesNo
Send Invoice to for processing:*

First NameLast Name
Phone Number:*
E-mail:*
** LOCATION OF REQUEST ** - Choose below
Site & Building Info:*
Sites listed above are on file for previous service. If your location is not listed, please provide details below.
(Please provide name and address of new location)
Site:
Building:
Floor:
Specific room number: *
(HOSPITAL FACILITIES WILL NEED A PERMIT - IF YOU DON'T HAVE ONE THEN YOU CAN PUT N/A)
Department Name:
(ex. ICU, ENDO, OR Services)
Suite#:
(If available)
Preferred day?:
Preferred time?:
*** WHAT IS THE REPAIR NEEDED, APPROVING PARTY, BILLING INFO ***

Please Specify Below

*WORK WILL BE COMPLETED AS REQUESTED AND BILLED AT TIME AND MATERIAL RATES*
Send Invoice to:*

First NameLast Name
E-mail:*
Pick a task:
NOTE - Please check with you dept. manager to see if a quote and PO is required prior to work being performed.
Please provide additional information related to this request if needed:
*** WORK TO BE PERFORMED NOW ***-- Please Specify Below

*WORK WILL BE COMPLETED AS REQUESTED AND BILLED AT TIME AND MATERIAL RATES*
Install Network Cables - (QTY):
(PC's, network printer, VOIP phone etc.)
Install Analog Cables : QTY
(fax, DID line etc.)
Other Item (please specify in box below):
NEED ASSISTANCE ? -- We are here to help!

Not sure exactly what you need to have done? Not a problem, please provide as much information as possible for what you are needing done. We will contact you to clarify and see how we can help.
ENTER DESCRIPTION HERE:
(picture, drawing etc.)
*** QUOTE REQUEST ONLY *** -- Please Specify Below

*NOTE - ALL QUOTES REQUIRE FORMAL APPROVAL PRIOR TO PROCESSING & SCHEDULING WORK TO BE DONE*
How many network/voice cables needed? - (QTY):
This is for standard data/voice cabling.
Need a quote for something else, no problem, provide specifics below :
If you have supporting documents such as a drawing, picture etc. Now is the time to add them.

Browse Files
Just drag and drop them in. Cancelof
Should be Empty:

S725 - HMB - MT. BELVIEU PCG @ 8608 N. Highway 146
S906 - HMB-BAYTOWN CAMPUS @ 4401 Garth Road
S644 - HMB-CANCER CENTER @ 4021 Garth Rd
S498 - HMB-GARTH ROAD HOSPITAL @ 4401 Garth Road
S848 - HMB-OPC (OUTPATIENT CENTER) @ 1666 West Baker Road
S613 - HMB-PLAZA 1 @ 4301 Garth Road
S614 - HMB-PLAZA 2 @ 4301 Garth Road
S597 - HMB-SURGERY CENTER @ 1677 West Baker Road
S1190 - HMB-UNITY TOWER @ 4401 Garth Road
S495 - HMCL-CLEAR LAKE CAMPUS @ 18300 St. John
S1001 - HMCL-CUP @ 18300 St John
S1008 - HMCL-DEER PARK ECC @ 3701 Center St.
S736 - HMCL-FAIRMONT PT/REHAB @ 6243 Fairmont Parkway
S998 - HMCL-FRIENDSWOOD PTOT @ 505 SOUTH FRIENDSWOOD DR.
S1002 - HMCL-FRIENDSWOOD-PCG @ 415 E. Parkwood Ave.
S606 - HMCL-HOSPITAL @ 18300 St. John
S1179 - HMCL-LEAGUE CITY ECC @ 1310 E. League City Parkway
S666 - HMCL-MOB1 BUILDING @ 2060 Space Park Dr.
S617 - HMCL-MOB2 (Old Sports) @ 18100 Houston Methodist Dr.
S607 - HMCL-MOB3 (AQUATICS) @ 18300 Houston Methodist Dr.
S1057 - HMCL-MOB4 BUILDING @ 18300 Houston Methodist Dr.
S796 - HMCL-TUSCAN LAKES ORTHO/PCG @ 2220 E. League City Parkway
S605 - HMCL-WEST BUILDING @ 18300 Houston Methodist Dr.
S936 - HMCY-CYPRESS ED @ 27560 US-290 Frontage Rd.
S1072 - HMCY-CYPRESS HOSPITAL @ 24500 Northwest Fwy
S1036 - HMCY-CYPRESS PCG @ 25282 Northwest Freeway
S1170 - HMCY-FAIRFIELD PCG @ 28606 Northwest Freeway
S1241 - HMCY-MOB1 @ 24500 Northwest Fwy
S1242 - HMCY-MOB2 @ 24500 Northwest Fwy
S1044 - HMCY-TOWNE LAKE - STE.200 @ 9915 Barker Cypress Rd Ste.200
S970 - HMCY-TUCKERTON @ 18121 Tuckerton Rd.
S600 - HMCC-HOSPITAL (OLD ST. CATS) @ 701 S Fry Rd, Katy, TX 77450
S750 - HMCC-MOB (Old St. Cats) @ 701 South Fry Road
S635 - HMWH-CINCO RANCH ED @ 26000 Farm to Market 1093
S801 - HMWH-KATY IMAGING @ 8333 Katy Fwy
S629 - HMWH-KINGSLAND @ 23530 Kingsland Blvd.
S1199 - HMWH-LOGISTICS CENTER @ 29903 US-90
S582 - HMWH-MAIN HOSPITAL @ 18500 Katy Fwy.
S583 - HMWH-MOB1 @ 18500 Katy Frwy.
S584 - HMWH-MOB2 @ 18500 Katy Frwy.
S1209 - HMWH-MOB3 @ 18700 Katy Freeway
S650 - HMWH-SPRING VALLEY VILLAGE @ 9090 Katy Freeway Level 2
S500 - HMWH-WEST HOUSTON CAMPUS @ 18500 Katy Frwy.
S1108 - HMH - KINGS HARBOR PCG/SPG @ 4501 Magnolia Cove
S1037 - HMH - KINGWOOD PCG @ 19701 Kingwood Dr. Ste. B
S587 - HMH - ANNEX @ 1130 Earle St.
S1126 - HMH - ARAMCO - (3 ALLEN CTR) @ 333 Clay Street, 5th Floor
S1034 - HMH - BELLAIRE #1 - STE.175 @ 4710 BELLAIRE BLVD
S882 - HMH - BELLAIRE #2 @ 4710 Bellaire Blvd.
S1173 - HMH - BELLAIRE #3 - SUITE 390 @ 4710 Bellaire Blvd.
S1172 - HMH - BELLAIRE #4 - STE 420 @ 6750 W Loop S.
S1033 - HMH - BELLAIRE PCG - STE.250 @ 4710 BELLAIRE BLVD
S946 - HMH - BELLAIRE PLACE @ 4800 Fournace Place
S1035 - HMH - BUFFALO PCG @ 5510 BUFFALO SPDWY STE.200
S1159 - HMH - CBO LOCATION @ 1213 Hermann Drive, Houston
S868 - HMH - DYNAMO SPORTS @ 12211 Kirby Dr.
S865 - HMH - EL CAMINO @ 14903 El Camino Real
S585 - HMH - GREENBRIAR @ 8100 Greenbriar St
S811 - HMH - HEIGHTS @ 1001 Studewood St #200b
S769 - HMH - HOLLY HALL DATACENTER @ 2550 Holly Hall
S501 - HMH - HOLLY HALL OFFICE BLDG @ 2550 Holly Hall
S591 - HMH - KIRBY BREAST CENTER @ 2615 Southwest Fwy.
S590 - HMH - KIRBY ECC @ 2615 Southwest Frwy.
S588 - HMH - KNIGHT ROAD @ 8303 Knight Road
S1038 - HMH - LONG MEADOW - STE.100 @ 7789 W. Grand Parkway South
S845 - HMH - MEMORIAL GREEN @ 12505 Memorial Drive
S1041 - HMH - MEMORIAL PCG @ 7575 San Felipe St. Ste.155
S1014 - HMH - MEMORIAL PTOT @ 9090 Katy Fwy.
S920 - HMH - MUSEUM TOWER @ 1213 Hermann Dr., Ste. 300
S589 - HMH - PARNELL WAREHOUSE @ 7702 Parnell St
S651 - HMH - PIN OAK @ 5505 West Loop S.
S1184 - HMH - SOUTHSIDE COMMONS PCG @ 4191 Bellaire Blvd
S973 - HMH - TEXAS CITY SPORTS MED. @ 1310 34TH ST. N. STE D
S572 - HMH - VOSS ED @ 1635 S Voss Rd
S586 - HMMC - SUNSET (3 STORY BLDG) @ 1707 Sunset Boulevard
S558 - HMMC-DUNN TOWER @ 6560 Fannin St.
S561 - HMMC-FONDREN/BROWN @ 6565 Fannin St.
S957 - HMMC-JOSIE ROBERTS ADMIN @ 7550 Greenbriar Dr.
S559 - HMMC-MAIN BUILDING @ 6565 Fannin St.
S494 - HMMC-MEDCENTER CAMPUS @ 6565 Fannin St.
S563 - HMMC-MGJ BUILDING @ 1130 John Freeman Blvd
S562 - HMMC-NEURO/JONES TOWER @ 6565 FANNIN
S568 - HMMC-OUTPATIENT CENTER (OPC) @ 6445 Main St
S564 - HMMC-RESEARCH INSTITUTE @ 6670 Bertner Ave
S565 - HMMC-SCURLOCK TOWER @ 6560 Fannin St
S566 - HMMC-SMITH TOWER @ 6550 Fannin St.
S993 - HMMC-SUNSET-(6 STORY BLDG) @ 1701 Sunset Blvd
S1183 - HMMC-TWU GARAGE @ 6700 FANNIN
S608 - HMMC-WALTER TOWER @ 6551 Bertner Ave, Houston
S567 - HMMC-WEST PAVILION @ 6447 Main St
S986 - HMH - PEARLAND CCC (HUB) @ 8520 Broadway
S634 - HMH - PEARLAND ED @ 11525 Broadway St
S1105 - HMSL- ALIANA @ 10745 West Grand Parkway South
S574 - HMSL-BRAZOS TOWER @ 16655 Southwest Freeway
S594 - HMSL-BROOKS @ 1201 Brooks St
S575 - HMSL-CANCER CENTER @ 16655 Southwest Freeway
S670 - HMSL-FONDREN SUITE 209 @ 2500 Fondren Rd.
S699 - HMSL-LONG MEADOW @ 7790 West Grand Pkway South
S573 - HMSL-MAIN HOSPITAL BUILDING @ 16655 Southwest Freeway
S569 - HMSL-MOB1 @ 16651 Southwest Freeway
S570 - HMSL-MOB2 @ 16659 SW Freeway
S571 - HMSL-MOB3 @ 16605 Southwest Freeway
S1192 - HMSL-MOB4 @ 16605 Southwest Freeway
S595 - HMSL-MOST BUILDING @ 16655 Southwest Fwy.
S1043 - HMSL-RIVERSTONE PCG - STE.105 @ 18717 S. University BLVD
S1147 - HMSL-ROSENBERG PCG @ 4050 FM 762 RD.
S908 - HMSL-SIENNA ECC @ 8200 Hwy 6
S896 - HMSL-SIENNA HUB @ 8330 Hwy 6 Ste 200
S497 - HMSL-SUGARLAND CAMPUS @ 16655 Southwest Freeway
S596 - HMSL-SWEETWATER @ 16655 Southwest Fwy,
S662 - HMSL-TOWN CENTER @ 4780 Sweetwater Blvd.
S925 - HMTW - CONROE HUB @ 4015 I-45 North Ste.100
S1040 - HMTW - MAGNOLIA PCG @ 18230 FM 1488
S1042 - HMTW - RAYFORD PCG - STE. 102 @ 30014 Aldine Westfield Rd.
S996 - HMTW-CUP @ 17201 Interstate 45 South
S671 - HMTW-ECC @ 3759 Farm Market Rd 1488
S576 - HMTW-HOSPITAL @ 17201 Interstate 45 South
S1089 - HMTW-INFUSION CENTER @ 8000 TX-242
S1193 - HMTW-MAGNOLIA ECC @ 18230 FM 1488
S577 - HMTW-MOB1 @ 17183, I-45
S698 - HMTW-MOB2 @ 17183, I-45
S733 - HMTW-MONTGOMERY II PCG @ 21300 Eva St.
S1203 - HMTW-RIVER POINTE STE.110 @ 1501 River Pointe Dr.
S997 - HMTW-SPORTS MEDICINE @ 7990 State Hwy 242
S847 - HMTW-STERLING RIDGE @ 6704 Sterling Ridge, Suite A
S496 - HMTW-THE WOODLANDS CAMPUS @ 17201 Interstate 45 South
S1045 - HMH - WHARTON CARDIOLOGY @ 205 N Alabama Rd.
S667 - HMWB - SPRING ECC @ 5303 FM 2920 Rd
S1012 - HMWB - TOMBALL PCG @ 14211 FM2920 - Suite 110
S1160 - HMWB-ANNEX @ 7800 Willowchase Blvd
S1106 - HMWB-ATH NORTH @ 19711 Stuebner Airline Rd.
S581 - HMWB-CENTERFIELD BULDING @ 13802 Centerfield
S895 - HMWB-CENTRAL PLANT @ 18220 State Highway 249
S672 - HMWB-FRENCH QUARTER @ 7105 FM2920 French Quarter
S724 - HMWB-HARGRAVE BUILDING @ 18220 Tomball Pkwy
S1039 - HMWB-LOUETTA @ 10130 Louetta Rd. Ste. G
S580 - HMWB-MOB 1 @ 18220 State Highway 249
S578 - HMWB-NORTH PAVILION @ 18220 State Highway 249
S579 - HMWB-WC&P (SOUTH PAVILION) @ 18220 State Highway 249
S499 - HMWB-WILLOWBROOK CAMPUS @ 18220 State Highway 249
(NOT LISTED - ENTER NEW SITE)

SERVICE WORK REQUEST

Who is requesting the work?

Who is the onsite contact?

Who is approving this request?

Who is to receive the invoice?