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Request a Physician Appointment

To request an appointment with a MedStar Franklin Square Medical Center physician, please fill out the secure form below. The information you provide will remain strictly confidential and will help us schedule your appointment appropriately. By providing complete information, it will help us serve you better and more efficiently schedule your appointment.

A representative from MedStar Franklin Square Medical Center will call you as soon as possible with the appointment date and time; however, it may take up to two business days to confirm.

If you would like to speak with someone directly, please call the physician referral service, Monday through Friday, 9 a.m. - 6 p.m., at 443-777-7900. Please note: We are not able to provide any medical diagnoses or consultations via phone or e-mail.

The physicians participating in this service have agreed to accept referrals and are approved for clinical privileges at MedStar Franklin Square Medical Center.

If this is an emergency, please call 911 immediately.

Patient Information *Indicates required information
First Name *   
Last Name *   
Home Address *  
 
City * State * Zip Code *
     
Date of Birth *   
Gender 
Are you seeking an appointment with a specific doctor? If so, please type physician name here.  
Reason for appointment    
If other, please describe the reason for your appointment.  (Limit entry to 250 characters.)  
Is this your first appointment or are you a returning patient? * 
Do you have health insurance? *
 
Insurance Name*
Have you received a physician referral for this appointment? 
Preferred day(s) of week for your appointment.  

Preferred time of day 
Contact Information of Person Requesting Appointment
Your First Name (if different from patient name) 
Your Last Name (if different from patient name) 
Your Relationship to Patient 
Daytime Phone Number *   
What is the best time to contact you? 
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Would you like to receive the following publications? 

E-mail Address
E-mail Address Expected Delivery Date
How did you hear about us? 
 

Please note: When you register at any MedStar Health site, your information remains strictly confidential. As always, MedStar Franklin Square Medical Center and its parent company, MedStar Health, respect your privacy. The information you submit is used for internal purposes only to help guide us in developing health information relevant to your needs. Read our privacy policy here...