Georgetown University Hospital

Appointment Request Form

Thank you for choosing Georgetown University Hospital for your healthcare services. Please complete our appointment request form and one of our healthcare professionals will contact you. 

If you are experiencing a medical emergency, please call 9-1-1 immediately.

This appointment request form is secured, and the information that you provide is confidential. If you prefer to speak with a Georgetown M.D. (medical directory) nurse counselor who can schedule your appointment with one of our expert physicians, please call 202-342-2400 or 866-745-2633. Nurse counselors are available Monday through Friday, 8 a.m. to 8 p.m.

* required information

Patient Information
Title*    
First Name*    
Middle Name*    
Last Name*    
Gender*    
Date of Birth*  (dd/mm/yyyy)  
Address*    
City*    
State*    
    Zip*      
Country  
Insurance Provider*    
Primary Telephone Type*    
Primary Telephone Number*    
Secondary Telephone Type  
Secondary Telephone Number  
Email address*    
Retype email address*    
 
Reason for Appointment*
   
How did you learn about Georgetown University Hospital?*

   

If other: 

Would you like to receive health-related information from Georgetown University Hospital?*