Appointment Request
MedStar Unio Memorial Hospital

Request an Appointment

To request an appointment with a MedStar Union Memorial 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 410-554-2266, 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.

Requestor Information
I am requesting this appointment for someone else
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* 
  Back Pain Elbow Foot / Ankle Hand/Wrist  
  Heart / Cardiac Hip / Knee Shoulder Vascular Other
Please describe your symptoms and/or existing medical condition.

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How long have you had these symptoms?

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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
First Choice
Second Choice

The physicians participating in this service have agreed to accept referrals and are approved for clinical privileges at MedStar Union Memorial Hospital.

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