Appointment Request


Request a Physician Appointment

To request a first appointment with a MedStar Good Samaritan Hospital physician, please fill out the form below. By providing complete information, it will help us serve you better and more efficiently schedule your appointment.

A representative from MedStar Good Samaritan Hospital 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 443-444-4100. 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 Good Samaritan Hospital.

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 
Physician appointments are available for the following specialties. For a personal referral to any other physicians, please call 443-444-4100.  
Are you seeking an appointment with a specific doctor (from one of the specialties listed above)? If so, please type physician name here.  
Reason for appointment. Please describe your symptoms and/or existing medical condition(s). * 
When did your symptoms begin? * 
Do you have health insurance? *


Insurance Provider
Provider Name *
Policy Number  Group Number 
Have you received a physician referral for this appointment? 
Preferred day(s) of week for your appointment.  
No Preference Monday
Tuesday Wednesday
Thursday Friday
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? 
Email Address
Request Good Information from Good Samaritan
Would you like to receive our Focused on You newsletter? 

How did you hear about us? 
 

Please note: When you register at any MedStar Health site, your information remains strictly confidential. As always, MedStar Good Samaritan Hospital 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...