MedStar Good Samaritan Hospital Appointment Request

Request an Appointment

To request an appointment with a MedStar Good Samaritan Hospital physician, please fill out the form below. A representative will call you within one business day; however, it may take up to two business days to confirm.

If you would like to speak with someone directly, please call 443-444-4100, Monday through Friday, 9 a.m. - 6 p.m. Please note: We are not able to provide any medical diagnoses or consultations via phone or e-mail.

If this is an emergency, please call 911 immediately.

* required information

Requestor Information

I am requesting this appointment for someone else:	No Yes
Your First Name
Your Last Name
I am submitting this request for my:
Daytime Phone Number*	- -
What is the best time to contact you?
How did you hear about us?

Patient Information

First Name*		MI	Last Name*
Home Address*
City*		State*	Zip Code*
Date of Birth*	/ /		Gender*

Reason for Contact*

Please describe your symptoms and/or existing medical condition.*	characters remaining
How long have you had these symptoms?	characters remaining

Have you been treated for this condition in the past?	Yes No
Do you have current medical work-ups (MRI, x-rays, etc.) performed in the last 3 months?	Yes No
If you are seeking an appointment with a specific doctor, please type physician name here.
Health Insurance Provider

Preferred day of week for your appointment

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